Prescribing & Medicines
Management
page PM2-3
December 2007
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Features |
Current issues affecting PCO activity
A definition of medicines management from the National Prescribing Centre is “a system of processes and behaviours that determines how medicines are used by patients and by health care services”. This comprises many facets, most of which are always on the agenda. Prescribing
is the most common intervention in the NHS and the number of non-medical
prescribers is growing. The complexity, volume and cost of medicines
is increasing, and about 11 per cent of a primary care organisation’s
total budget is spent on primary care prescribing. We know that up to
50 per cent of patients with long-term conditions do not use their medicines
as intended and medicines-related problems contribute to between 5 and
17 per cent of hospital admissions. As the revisions to the GMS contract 06/07 (annex 8) say, “improving the quality, cost-effectiveness and affordability of prescribing in the context of the overall use of NHS resources is of benefit to patients”. All the interventions that PCOs commission, including drugs, need to be effective (ie, have patient-oriented evidence), be cost-effective (however that is defined) and be affordable (only the local PCO can decide this). Much of the current target driven prescribing does not fit these criteria. PCOs should also ask: what is the opportunity cost (ie, what health gain could have been achieved by spending those funds on another intervention)? Cholesterol
lowering Are your prescribers trying
to achieve Joint British Societies’ guidelines on prevention
of cardiovascular disease in clinical practice (JBS2) targets for low
density lipoprotein cholesterol
levels? This is not evidence-based, so cannot be cost-effective and is
certainly not affordable. In clinical trials the use of atorvastatin
80mg daily only gets about half of patients to this target. Importantly, it highlights that there is no strong and
conclusive evidence on the exact relationship between cholesterol lowering
and clinical
end-points. It points out that without trials reporting clinical outcomes,
effectiveness in reducing total and LDL-cholesterol does not prove these
reductions translate into comparable reductions in clinical events. Diabetes The use of glitazones is causing some concern. Despite a lack of hard outcome data and a limited place in the National Institute for Healthcare and Clinical Excellence guidance, prescribing and expenditure have grown significantly over the past few years. The risk of heart failure with glitazones has been known for some time and we now have the additional risks of fractures in women (class effect) and myocardial infarction with rosiglitazone.3 With many other available oral agents for diabetes, the potential benefit of glitazones requires re-evaluation. PCOs should be updating their local guideline along the following lines: • Maximise the use of metformin (initiate at low dose and titrate up
slowly, consider using slow release products if appropriate) and avoid
unnecessary use of glitazones Anti-inflammatories Is diclofenac the favourite non-steroidal anti-inflammatory in your area? If so, this probably needs to be looked at. Two reviews suggest that diclofenac has the highest risk of cardiovascular events of the non-selective NSAIDs, while naproxen was associated with no apparent increase in risk.4,5 Further evidence comes from the MEDAL study6 in which diclofenac 150mg daily had an increased risk of thrombotic events similar to that of licensed doses of etoricoxib. The use of diclofenac was associated with about four extra cardiovascular events (mainly MI) for every 1,000 patients treated for a year, consistent with the increased risk for selective COX 2 inhibitors. Anti-platelets Are you concerned with the level of clopidogrel prescribing? Used alone, this drug should be reserved for patients with vascular disease who are unable to take low dose aspirin because of allergy, intolerance or contraindication. For combination use with aspirin, is NICE guidance being followed? Is there significant off-licence use? There is concern that once clopidogrel gets on a repeat prescribing system it is not stopped when appropriate. After an acute coronary syndrome, NICE recommends 12 months of clopidogrel. Normally patients will be discharged with 28 days’ supply and primary care will be responsible for prescribing the rest of the course. It is imperative that a stop date for the clopidogrel is noted and acted on. One solution could be to include this on the prescription so that the stop date appears on the label (eg, “Take one daily until 31 October 2008 and then stop”). The doctor, pharmacist, and, importantly, the patient then know when to stop. Neuropathic pain Prescribing levels of gabapentin and pregabalin have also been causing sleepless nights. PCOs should consider a local guideline on the primary care management of neuropathic pain, with the aim of reducing inappropriate and unnecessary referrals to pain clinics. A recent systematic review investigated treatments for symptoms of painful diabetic neuropathy.7 The review found that tricyclic antidepressants (TCAs) are most effective in reducing pain by 50 per cent (odds ratio 31.73), followed by traditional anticonvulsants (sodium valproate, carbamazepine) (OR 7.59), and the newer generation anticonvulsants (gabapentin, oxcarbazepine, pregabalin) (OR 3.25). The newer anticonvulsants are most likely to cause withdrawals due to adverse events, followed by TCAs and the traditional anticonvulsants (OR 2.98, 2.32 and 1.51, respectively). In the analysis of the effects of tramadol the OR for withdrawal due to adverse events was higher than the OR for 50 per cent pain relief. The authors’ proposed treatment algorithm is a TCA first-line, or if there are contraindications to a TCA, sodium valproate or carbamazepine. Is this what happens in your area? I have run out of space to mention asthma and chronic obstructive pulmonary disease and to discuss the use of analogue insulins, and I am sure there are many other issues in medicines management that readers can identify. 1. Minhas R. Eminence-based guidelines: a quality assessment
of the second Joint British Societies’ guidelines on the prevention of cardiovascular
disease. Available at www.blackwellpublishing.com (accessed
7 November 2007) |