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Prescribing and QiPP 2011

Prescribing and QiPP 2011. Anne-Marie Bailey Associate Lead for Medicines Management NHS south of Tyne & Wear . QiPP. Q uality I nnovation P roductivity P revention. How will this be achieved?. 4 key regional programmes: Efficient use of medicines

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Prescribing and QiPP 2011

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  1. Prescribing and QiPP 2011 Anne-Marie Bailey Associate Lead for Medicines ManagementNHS south of Tyne & Wear

  2. QiPP • Quality • Innovation • Productivity • Prevention

  3. How will this be achieved? 4 key regional programmes: • Efficient use of medicines • Repeat medication management – supporting patients • Procurement • Local Decision-Making – Effective Commissioning

  4. Local Decision Making • Area Prescribing Committee • Joint committee between PCT and FT • Regional decision making • NETAG (North East Treatment Approvals Group) • NECDAG (North East Cancer Drugs Approval Group) • Formulary development

  5. Formulary Development • Seamless care • Familiarity with drugs • Cost-effective prescribing • Safety • Tolerability • Effectiveness • Price

  6. Traffic Light System • RED = hospital prescribing only • AMBER = shared care • Should be started in hospital • Can be handed over to primary care with appropriate documentation • GREEN PLUS = started in secondary care, less specialised monitoring etc needed • GREEN = can be started in primary care

  7. Dabigitran and Non-valvular Atrial Fibrillation • NETAG review in June 2011 • Warfarin will remain first line treatment for AF • Dabigatran can be considered for patients with an allergy or absolute contra-indication to warfarin • Cost impact currently being evaluated to extend Dabigitran to patients who are not adequately treated on warfarin or whose INR is unstable • A bleeding risk that would lead to a contra-indication to warfarin would also contra-indicate to Dabigatran • Dabigatran should be specialist initiated at present

  8. Gaviscon Advance Doxazosin MR Prednisolone EC Escitalopram Diclofenac (oral) Diclofenac (topical) Venlafaxine MR Famciclovir 750mg 1 daily Peptac Doxazosin Prednisolone Citalopram (or sertraline) Naproxen Piroxicam Venlafaxine standard Aciclovir 800mg 5x daily QIPP – current work

  9. Prescribing Terminology ASTRO-PUs Age Sex Temporary Resident Originated Prescribing Units STAR-PUs Specific Therapeutic Group Age-Sex Related Prescribing Units ADQ Average Daily Quantity NIC Net Ingredient Cost

  10. Esomeprazole: 20mg tablets £18.50 40mg tablets £25.19 Lansoprazole: 15mg capsules £1.22 30mg capsules £1.89 15mg FasTabsTM £2.99 30mg FasTabsTM £5.50 Pantoprazole: 20mg tablets £1.34 40mg tablets £2.08 Rabeprazole: 10mg tablets £11.56 20mg tablets £19.55 Omeprazole: 10mg capsules £1.57 20mg capsules £1.62 40mg capsules £6.68 10mg MUPSTM tablets £7.75 20mg MUPSTM tablets £11.60 40mg MUPSTM tablets £23.20 10mg tablets £5.63 20mg tablets £5.17 40mg tablets £25.12 56 = £3.24 <half cost PPI PrescribingPrices for 28 doses fromDrug Tariff, September 2011

  11. Statins summary • Simvastatin = first-line • Simvastatin or pravastatin ONLY in primary prevention • No targets for primary prevention • Atorvastatin 80mg is being used in ACS • Ezetimibe – only if all statins not tolerated • Familial Hypercholesterolaemia – specialist referral

  12. NICE guidance: ACE inhibitors first-lineNICE CG34 Hypertension, 2006; NICE CG5 Heart Failure, 2003; NICE CG48 MI: secondary prevention, 2007; NICE CG87 Type 2 diabetes, 2009; NICE CG73 Chronic kidney disease, 2008 • No evidence that A2RAs are superior to ACE inhibitors • No evidence that A2RAs are safer than ACE inhibitors • A2RAs do not reduce risk of MI vs. placebo • A2RAs cause less cough than ACE inhibitors but difference is small (absolute difference in discontinuation due to cough 3% in ONTARGET) • Generic ACE inhibitors are less expensive than A2RAs • Possible increase in fatal CV events with Olmesartan

  13. Clopidogrel 75mg Plavix 75mg Clopidogrel Hydrogen Sulphate 75mg Cost for 30 tablets £2.41 £35.64 £35.64 Clopidogrel generic prescribing

  14. Hypoglycaemic Agents1st line Metformin: 2nd line Sulphonylureas • Metformin – only hypoglycemic agent to reduce total mortality, diabetes related deaths and CV events (Mortality NNT 14 over 10.7yrs UKPDS) • Sulphonylureas can be used first line if significant osmotic symptoms and a rapid response is needed. • Small increased risk of bladder cancer with Pioglitazone (ARI 0.08% NNH 1250) • Increase risk of heart failure (NNH 62 over 3 years) and fractures with glitazones (NNH 55 for 1 yr in women average age of 56) • No long term safety data for gliptins or GLP-1s • Reports of pancreatitis and acute renal failure with GLP-1s

  15. Insulin analoguesNICE CG 87 May 2009 • Long acting Insulin analogues should be reserved for patients with:- • Problematic hypoglycaemia • Require assistance to administer and monitor their injections • NPH insulins are preferred insulin (Insulatard, Insuman basal and Insulin I) • Reviews of studies comparing insulin analogues with standard non analogue insulins found no major clinical differences • Long term safety of insulin analogues is unknown • Analogues are 1.7-1.8 times more expensive than standard insulin

  16. Cephalosporin & Quinolone Prescribing • Regionally, second and third generation cephalosporins and clindamycin are restricted to reduce the risk of MRSA and C.difficile • Quinolones and cephalosporins should be reserved to treat resistant disease • Avoid cephalosporins or quinolones in patients at high risk of HCAIs – over 65’s, LTCs requiring recurrent antibiotics, recent hospital admission, institutionalised • Quinolones are recommended first line by the HPA only in limited situations (e.g. acute pyelonephritis or acute prostatitis)

  17. “Safer NSAIDs” • Naproxen • Ibuprofen ≤ 1200mg daily Review patients: • Over 65 years of age • With CVD, PVD, Heart failure and diabetes • With hypertension • Active or history of Peptic Ulcer Disease

  18. 1st line Alendronic Acid 10mg Alendronic Acid 70mg 2nd line Risedronate 5mg Risedronate 35mg 3rd line Strontium Ranelate Denosumab Inj Cost for 28 days £1.56 £1.16 (Branded £22.80) £17.54 £2.20 (Branded £19.12) £27.08 £28.47 (not inc. admin costs) Generic Alendronate and % Alendronate as a proportion of bisphosphonates

  19. NICE Guidance: Bisphosphonates first lineNICE TA 160: October 2008. NICE TA 161: October 2008:NICE TA 204: June 2011 • First line Alendronic Acid • Second line Risedronate • Third line Strontium Ranelate or Denosumab • No difference in the risk of serious upper GI reactions has been demonstrated between alendronic acid and risedronate

  20. Benzodiazepines prescribing • If prescriptions are issued, they are short term, small quantities and controlled • Newly registered patients are not issued with prescription until reviewed by GP they are then strongly encouraged to withdraw • Practice policy for “troublesome patients” – lost prescriptions, lost medication, left at relatives, eaten by the dog…… • Blanket no prescribing of z drugs • Avoid dual prescribing of benzodiazepines e.g. Diazepam and Temazepam’ • Consider using other alternative drugs for anxiety, depression, chronic pain

  21. Diazepam 2mg (whites) Diazepam 5mg (yellows) Diazepam 10mg (blues) Temazepam 10mg (wobbly) Zopiclone 7.5mg Amitriptyline 1 sm strip (tripline) 25p 50p £1 £1 £2 £1 Street prices (2010)

  22. Other drugs associated with diversion • Dihydrocodeine • Tramadol • Codeine • Gabapentin • Pregabalin • Methadone & Buprenorphine • Methylphenidate • Dexamfetamine

  23. Wound management and sip feeds • Formularies have been developed in most PCOs across the SHA region • Exploring option of procurement of dressings and sip feeds on contract and other “off prescription” routes of supply • Department of health are looking to devolve budgets to provider services

  24. Specials • Prescribe a licensed medicine first-line • ALWAYS • Licensed liquid may be more expensive than crushing tablet option • NOT NEGOTIABLE • Crushing tablet is unlicensed BUT • So is a special (unlicensed liquid) • RPS guidance available

  25. Specials • Quetiapine 12.5mg/5ml for swallowing difficulties • £299.32 for 1120ml • OR tablets can be crushed and mixed with water (£33.83 for 60 x 25mg) • or alternative drugs have liquid options: amisulpiride, risperidone, olanzapine (oro-disp) and aripiprazole (oro-disp)

  26. Anti-Dementia Drugs – Off Patent Formulations • Rivastigmine is now off patent, Donepezil in January 2012 and Galantamine in Summer 2012 • New novel formulations now being introduced which are more costly – Galantamine MR, Rivastigmine patches and Donepezil orodispersible tablets • Regionally, MMTs are working with Acute and Mental Health Trusts to ensure cost growth is contained by remaining with the older formulations

  27. CD e-learninghttp://www.npc.nhs.uk/controlled_drugs/less_than_sixty.php • Controlled drugs e-learning available for practices (25 min PowerPoint presentation) • Presentation covers all aspects of controlled drugs management from ordering through to destruction and prescribing • Useful for:- • practices who store CDs • individual GPs holding CDs in doctors bag • GP registrars or new GPs to the practice

  28. Safety issues • Aspirin and reduction in cancer risk • Implanon and contraceptive failure • NPSA safer use of insulin alert • Inhaled corticosteroids and risk of diabetes • Olmesartan and possible increased risk of CV death • Mixing of medicines (syringe drivers and nebules) • NPSA patient passports – Lithium, insulin and warfarin

  29. Useful links • Gateshead Information Network (GIN) • www.gin.sotw.nhs.uk • National Prescribing Centre (NPC) • www.npc.co.uk (Therapeutics) • Electronic Medicines Compendium • www.medicines.org.uk

  30. Any Questions?

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