Medicine Management

1
Medicine Management

• Kiran Patel
• Greenmount Medical Centre

2
Prescribing

• Important aspect of a doctors job
• Contractual obligation for GPs
• Core element of RCGP Syllabus

3
High volume

• 1.3 of the population consults a GP/day
• 50-60 receive a prescription
• 720m prescriptions items issued/year
• 1.8m prescriptions items issued/day
• 65 items per GP/day
• Prescription cost analysis (DH 2005)

4
High cost

• NHS Budget 2005 76 bn
• 7.9bn / year
• 10 of NHS Budget
• But
• gt 50 on Staff
• Prescription cost analysis PCT allocation (DH
  2005)

5
(No Transcript)
6
Highly Complex

• Improved life expectancy
• Increased disease burden
• More aggressive treatment
• Polypharmacy
• Incomplete evidence base

7
RCGP Syllabus Pharmaco-therapeutics

• Application of the concept of rational
  prescribing, especially with regard to patient
  safety
• Awareness of drug contraindications, adverse
  effects, iatrogenic disorders and potential
  interactions
• Awareness of the factors affecting dose, drug
  requirements, compliance and monitoring
• Evaluating independent evidence regarding the
  appropriateness of treatment

8
High volume
High cost
Highly complex
High priority Highly trained ?
9
What are we going to cover

• Medication errors
• Medication reviews
• PACT
• Special situations

10
Medication errors

• The NHS can damage your health
• Avoidable adverse events are common
• Tolerance of error in the NHS is high
• NHS strategies for reducing error are ineffective
• Organisation with a memory (2000)
• Making Amends (2003)

11
Terminology

• Medication errors
• Adverse drug reaction (ADR)
• Side effects

12
Why are medication errors important?

• They kill people and make people ill
• 6th cause of death in the USA (1994)
• Healthcare time and resources
• 6 10 of hospital admissions
• Litigation
• MPS study - 19.3 of negligence claims (Silk
  2000)
• MDU study 25 of settled general practice
  claims (Green 1996)

13
Why are medication errors important?

• Cause or mimic disease
• Dyspepsia with NSAIDs
• Reduce QOL
• Side-effects
• Effect trust / confidence
• Avoidable

14
How common are they?

• We dont know
• ADRs occur in 10-20 of all patients prescribed
  drugs
• ADRs responsible for 5-10 of all admissions
• FGH MAU 10-20
• 6.7 of hospital patients suffer a serious ADR
• 0.1-0.3 of hospital patients suffer a fatal ADR
• Polypharmacy
• 11 with one drug 26 with 6 drugs
• Becoming more common
• BMJ 19983161295-1298

15
Are you worried?

• Overall drugs are remarkably non-toxic
• Vast majority of ADRs are minor and reversible

16
Are they avoidable?

• No all drugs carry risks of ADR
• Any drug that does not cause adverse effects is
  probably totally ineffective (Sir Patrick Dunlop
  CSM)
• Prescribing is a matter of weighing up the risks
  against the benefits
• BUT
• 50 of ADRs leading to hospital admissions are
  due to inappropriate drug therapy

17
Medication errors

• Implies a system failure
• Not just a side effect to the drug

18
Why do medication errors occur

• Dispensing errors
• Patient concordance and compliance
• Monitoring of treatment
• Communication
• Administration
• Prescribing error

19
Why do medication errors occur

• Prescribing error
• Lack of knowledge about a patient
• Lack of knowledge about the drug
• Failure to utilise this information
• Ignoring support systems or rules
• Error in decision making
• Calculation error
• Illegible prescriptions
• Confusing drug names
• Abbreviations, zeros decimal points
• Incorrect dosage instructions
• Who is prescribing

20
Adverse drug reaction

• The effect of the drug on the patient
• Prescription could be appropriate
• Or inapropriate
• Related to the drug
• Related to the patient

21
ADR - Classification

• Type A
• Predictable from the actions of the drug
• Dose dependent
• Common not severe
• Recognised before marketing
• gt dose adjustment

22
ADR - Classification

• Type B
• Unrelated to pharmacological action
• ? Immunological response
• Not dose related
• Rare but important and serious
• gt withdrawal of drug

23
ADR - Classification

• Type C
• Effects of chronic administration
• Adaptation to drug or change in sensitivity
• gt continue
• gt gradual phased withdrawal

24
ADR - Classification

• Type D
• Delayed effects
• Carcinogenesis
• Reproduction

25
How do we learn about ADRs

• Pre-marketing drug testing
• Post-marketing surveillance

26
Drug development process

• Pre-clinical testing
• Phased clinical trials
• I Single dose in healthy volunteers
• II Dose response in simple patients
• III Efficacy and safety in simple patients
• Licensed
• IV Post marketing studies

27
Post-marketing surveillance

• Yellow card
• Phase IV post-marketing studies
• Post-event monitoring (PEM) green card
• Safety alerts (MHRA)
• Black triangle scheme

28
Sources of information

• Summary of product characteristics (SPC)
• Medicines.org.uk
• MHRA
• BNF
• Drug bulletins
• Martindales

29
How reliable is this information?
30
Yellow card scheme

• West midlands 2001 received 1317
• 800 from primary care
• lt 16 per 100 000
• ie 0.016 of the population
• Compare this to ADR rate of 10 20
• Numbers are falling
• Do you know what to report?

31
Would you report?

• Rash with ibuprofen
• Confusion with tramadol
• Renal impairment with enalapril
• Urinary retention with amitriptyline
• GI upset with rosuvastatin

32
How reliable is this information?
33
How reliable is this information?

• Small numbers
• Short duration
• Simple patients
• Inadequate reporting

34
Case 1

• Mrs A 82y new patient
• Completes new patient registration card
• Request her repeat medication
• Which she needs today
• PMH IHD, RA, Depression
• Dx
• Methotrexate 10mg tabs as directed 100
• Prednisolone 5mg tabs - as directed 100
• Aspirin 300mg as directed 100
• Diclomax Retard as directed 30
• Cipralex as directed 30
• Co-proxamol as directed 100
• Lactulose as directed 500ml

35
Case 2

• Mrs B 52y
• Sees PN for BP check and is referred to you as BP
  is uncontrolled
• PMH HT, OA, Asthma, Oculo-pharyngeal dystrophy
  (dysphagia)
• Dx
• Bendroflumethiazide 2.5mg 1 od
• Enalapril 10mg 1 od
• Doxazosin 4mg 1 od
• Diclofenac EC 50mg 1 od
• Co-codamol effervescent - 2 qds
• Salbutamol inhaler 2 puffs prn

36
Case 3

• Mrs C 48y
• Community pharmacist asks you to review her as
  she is concerned about the concoction of drugs
  she is taking
• Using 24 sumatriptan per month and 8 co-codamol
  per day
• PMH Migraine, early surgical menopause,
  depression
• Dx
• Tibolone 2.5mg tabs 1 od
• Imigran 50mg tabs 1 prn
• Paroxetine 30mg tabs 1 od
• Co-codamol 30/500mg 1-2 qds prn

37
Case 4

• Mr D 59y
• Ex-smoker diagnosed with Type 2 DM 18m ago (BMI
  gt25)
• Poorly controlled DM started metformin
• 2m ago HbA1c 9.8 - rosiglitazone added as per
  PCT protocol
• BP high amlodipine increased from 5 to 10mg
• PMH Diabetes, HT
• Dx
• Rosiglitazone 4mg 1 od - Ramipril 10mg 1 od
• Metformin 500mg 1 tds - Aspirin 75mg 1 od
• Bendrofluamethazide 2.5mg 1 od - Amlodipine
  10mg 1 od
• Omeprazole 20mg 1 od - Celecoxib 100mg 1od

38
Strategies to reduce harm

• Identify vulnerable groups
• Identify problem drugs
• Set up robust systems

39
Which patients are at risk of ADRs?

• All patients - but especially
• Elderly
• Very young
• Housebound
• Nursing homes
• Mental illness
• More than 4 drugs
• Renal and liver disease
• Recently discharged from hospital

40
Drugs often implicated

• NSAIDs
• Anticogulants
• Antiarrhythmics
• Antipsychotics
• Diabetic medication
• Antibiotics
• Hypnotics

41
Medication Reviews

• Systematic activity
• Ad hoc
• Thorough
• Consider who carries out review

42
Medication review

• The NO TEARS tool
• Need and indication
• Open questions
• Tests and monitoring
• Evidence and guidelines
• Adverse events
• Risk reduction or prevention
• Simplification and switches
• BMJ  2004329434 

43
Medication reviews

• Review of patients on long term drug treatment is
  important but is done inadequately
• Evidence from the United States shows that
  pharmacists can improve patient care by reviewing
  drug treatment
• Consultations with a clinical pharmacist are an
  effective method of reviewing the drug treatment
  of older patients
• Review by a pharmacist results in more drug
  changes and lower prescribing costs than normal
  care plus a much higher review rate
• Use of healthcare services by patients is not
  increased
• Zermansky BMJ 20013231340

44
Strategies to reduce harm

• Medication reviews
• SEA
• Local schemes
• Pharmacist lead reviews
• Discharge follow ups
• Improve links to secondary care
• New pharmacy contract
• Electronic Transfer Prescription (ETP)
• EBM NICE

45
Summary

• MEs / ADRs
• Common
• Important
• Preventable
• gt Multifactorial approach

46
How do you sleep easier?

• Know your patient
• Know your drugs
• Obey rules
• Communicate with patients and colleagues
• Be vigilant about ADRs
• Make good records
• Report ADR
• Carry out regular medication reviews