The Pharmaceutical Journal
Vol 280 No 7494 p343
22 March 2008

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Drug Utilisation Research Group

Lin-Nam Wang (on the staff of The Journal) reports highlights from the 19th annual scientific meeting of the Drug Utilisation Research Group held in London in February

Prescribing and medicines management resources

Beware prescribing targets and guides

Prescribers need to be able to rely on external support to select, integrate and make good sense of evidence but, like clinical trial data, published tertiary data can be fraught with pitfalls, said Joe Collier, former editor of the Drug and Therapeutics Bulletin.

To assess the value of a drug, aspects include quality, relative safety, efficacy, cost, convenience, innovation and compassion, but a tertiary organisation might not consider all of these and this can result in opposing recommendations, such as that for Relenza from the National Institute of Healthcare and Clinical Excellence and the DTB. NICE looks at relative efficacy. It assumes safety but takes on board compassion.

In contrast, DTB looks at relative safety, efficacy, cost and convenience, Professor Collier said. “So, the principle is that if you’re going to choose a tertiary provider, choose one with the same interests [as you],” he advised.

Evidence is one of many influences on prescribing. Targets are another but target-based medicine could spell the end of prescribing freedom if targets do not reflect the subtleties of evidence, such as sub-population differences, and statistical anomalies, according to Alex Scharaschkin, from the National Audit Office.

“The challenge is in two parts: what you do about the population and what you do about the individual… [We] need to design targets that capture the evidence well,” he added.

Internet used to link warfarin patients to pharmacist anticoagulation management

Self-testing and using an internet system to link patients taking warfarin with a pharmacist result in better clinical outcomes than a traditional anticoagulation management service (AMS), according to a study conducted at University College Cork.

Patients (n=163) were randomly assigned to receive a traditional AMS or to self-test (using a CoaguChek XS device) and enter their international normalised ratio on to a secure website. Those using the website were prompted to report any missed doses, changes in diet or medicines, any illness and symptoms of bleeding and clotting.

If the INR is within therapeutic range and no problems have been reported, the patient is provided with instant feedback on what dose of warfarin to take and when to perform the next test. Patients with an INR outside the therapeutic range are asked to log on again later that day for instructions. The system relies on the pharmacist accessing the website at least twice a day.

He or she is alerted to review patients whose INR is outside therapeutic range or have other problems. Those with symptoms suggesting thromboembolism or haemorrhage are prioritised. On average it takes 24 minutes per day to manage patients using the system.

Interim results show the average period for the INR to be in therapeutic range for the internet users who completed six months of self-testing was 66.6 per cent compared with 57.2 per cent for the AMS patients. Patient self-testing enables more frequent INR measurements and this is associated with improved anticoagulation control — self-testing patients measure their INR once or twice a week compared with every four to eight weeks with traditional AMS.

In addition, the service removes several burdens for patients, said Fiona Ryan, PhD pharmacist at the university. For example, they do not have to travel to the clinic or pay for car parking. And the self-testing device gives a result in 30 seconds — an advantage over having to wait up to three hours in a busy clinic for results to be returned.

Restrictions to travelling are also removed — Ms Ryan described one patient being able to go on a cruise and continue managing his condition. She also noted that old age is not a barrier to home testing — the oldest patient in the study was 80 years old.

Although there have been some thrombotic events, there have been no major events so far, Ms Ryan said. The internet cased anticoagulation management system is currently being used in 45 hospitals in the US.

New tools to improve prescribing for elderly

Two screening tools to improve prescribing for old people have been developed at University College Cork. STOPP (screening tool of older person’s potentially inappropriate prescriptions) and START (screening tool to alert doctors to right treatment) consider diagnosis, drug-disease interactions, biochemical data and doses.

When applied to the profiles of 500 randomly selected patients over 65 years old STOPP identified 140 prescriptions as potentially inappropriate for 110 patients and START revealed that 139 medicines were not being prescribed when they were indicated, such as aspirin, statins, bisphosphonates and angiotensin-converting enzyme inhibitors.

A study showed that STOPP/START identifies more potential inappropriately prescribed medicines for patients in Ireland than Beers criteria and IPET (improving prescribing in the elderly tool), established tools in the US and Canada, respectively. The researchers claim that these tools would be useful for primary care in Ireland and the UK.

STOPP and START are currently paper-based but software is being developed.

Impact of lifestyle drugs

Media alarm over the huge cost implications of drugs such as sildenafil, bupropion and orlistat have not been borne out, according to the Regional Drug and Therapeutics Centre. Analysis of PACT data for the north east of England over 60 months has shown that the total financial impact is relatively small compared with total drug expenditure over the same period.

However, the centre warns that prescription volume of these drugs are rising and active management may be required to contain expenditure.

Initiatives better than campaigns

Primary care trusts should first direct resources at prescribing incentive schemes to reduce antibiotic prescribing before funding awareness campaigns, according to the Regional Drug and Therapeutics Centre.

Analysis of prescribing data for Greater Manchester shows that prescribing incentive schemes significantly reduced items/STAR-PU but awareness campaigns had no effect.