Medicines Optimisation Jane Portlock Professor of Pharmacy Education 19/09/2018

What is medicines optimisation? The changes in terminology over the last 30 years Pharmaceutical care 1980s Medicines Management 1990s Medicines Optimisation 2000 onwards 19/09/2018

Activities under the heading of medicines optimisation Clinical checking – already covered in dispensing, law and practice Clinical medication review* Medicines Use Review (MUR)* New Medicines Service (NMS)* 19/09/2018

Clinical Medication Review A definition of clinical medication review is “a structured, critical examination of a patient’s medicines with the objective of reaching an agreement with the patient about treatment, optimising the impact of medicines, minimising the number of medication related problems and reducing waste”. (Room for Review, 2002) 19/09/2018

Clinical Medication Review Principles of Clinical Medication Review · All patients should have a chance to raise questions and highlight problems about their medicines. · The medication review seeks to improve or optimise impact of treatment for an individual patient. · The review is undertaken in a systematic and comprehensive way, by a competent person. · Any changes resulting from the review are agreed with the patient. · The review is documented in the patient’s notes/PMR · The impact of any change is monitored. 19/09/2018

Clinical Medication Review Ensure patients are on optimum therapy by reviewing and making recommendations to improve therapy to the prescriber: • effectiveness of treatment; • appropriateness of treatment based on latest evidence; • adverse drug effects; • test results, interpreting them and acting on them where required; and • whether the recommendations of previous reviews have been acted upon; • recommend new treatments, e.g. aspirin or statins in CHD patients; and • if the pharmacist is a prescriber they would be able to make changes to the patient’s treatment as agreed with the doctor 19/09/2018

Clinical Medication Review Improve patient adherence with therapy by: • providing an opportunity for the patient to discuss concerns and ask questions about their medicines; • improving the patient’s understanding of their medicines; • simplifying the medication regimen and drug ordering process where appropriate; • identifying practical problems in medicine taking and referring the patient for assessment of support required if necessary; • providing advice and support to the patient and carer, including referral to specialist centres or other health and social care professionals where appropriate; and • ensuring that there is active participation of the patient, with shared decision making and agreement about any changes. 19/09/2018

Clinical Medication Review Patients at risk of medicines-related problems · taking four or more medicines every day · on a complex medication regimen or more than 12 doses in a day · recently discharged from hospital · recently transferred to care home · frequent hospital admissions · with multiple diseases · receiving medicines from more than one source e.g. specialist and GP · significant changes to the medication regimen in the past 3 months or more than 4 changes in medication in the past 12 months 19/09/2018

Clinical Medication Review · Patients at risk of medicines-related problems continued - Patients taking higher risk medicines - those requiring special monitoring e.g. lithium; those with a wide range of side effects e.g. NSAIDs; or a narrow therapeutic range e.g. digoxin; or on drugs not commonly used in primary care · symptoms suggestive of an adverse drug reaction · longstanding use of psychotropic medication · where non-adherence is suspected or known · high incidence of self medication 19/09/2018

Clinical Medication Review - patients with potential higher level of needs ·older people · residents in care homes · learning difficulties · sensory impairment e.g. sight or hearing · physical problems e.g. arthritis, swallowing difficulties · mental states such as confusion, depression, anxiety, serious mental illness · communication difficulties · literacy or language difficulties · minority ethnic groups · refugees and asylum seekers · living alone or poor carer support · recent falls 19/09/2018

Clinical Medication Review J Clin Pharmacol Ther. 2008 Feb;46(2):72-83. STOPP (Screening Tool of Older Person's Prescriptions) and START (Screening Tool to Alert doctors to Right Treatment). Gallagher P, Ryan C, Byrne S, Kennedy J, O'Mahony D. Department of Geriatric Medicine, Cork University Hospital, Wilton, Cork, Ireland. Abstract OBJECTIVE: Older people experience more concurrent illnesses, are prescribed more medications and suffer more adverse drug events than younger people. Many drugs predispose older people to adverse events such as falls and cognitive impairment, thus increasing morbidity and health resource utilization. At the same time, older people are often denied potentially beneficial, clinically indicated medications without a valid reason. We aimed to validate a new screening tool of older persons' prescriptions incorporating criteria for potentially inappropriate drugs called STOPP (Screening Tool of Older Persons' Prescriptions) and criteria for potentially appropriate, indicated drugs called START (Screening Tool to Alert doctors to Right, i.e. appropriate, indicated Treatment). METHODS: A Delphi consensus technique was used to establish the content validity of STOPP/START. An 18-member expert panel from academic centers in Ireland and the United Kingdom completed two rounds of the Delphi process by mail survey. Inter-rater reliability was assessed by determining the kappa-statistic for measure of agreement on 100 data-sets. RESULTS: STOPP is comprised of 65 clinically significant criteria for potentially inappropriate prescribing in older people. Each criterion is accompanied by a concise explanation as to why the prescribing practice is potentially inappropriate. START consists of 22 evidence-based prescribing indicators for commonly encountered diseases in older people. Inter-rater reliability is favorable with a kappa-coefficient of 0.75 for STOPP and 0.68 for START. CONCLUSION: STOPP/START is a valid, reliable and comprehensive screening tool that enables the prescribing physician to appraise an older patient's prescription drugs in the context of his/her concurrent diagnoses. 19/09/2018

STOPP and START review STOPP See E: Musculoskeletal system When is it inadvisable to prescribe a NON STEROIDAL ANTI-INFLAMMATORY DRUG (NSAID) in an older person and why? See A: Cardiovascular system What are the consensus recommendations for the prescribing of ASPIRIN in an older person and why? 19/09/2018

STOPP and START review START See A: Cardiovascular system Which medicines should be considered for people over 65 years of age and why? See E: Musculoskeletal system 19/09/2018

Medicines Use Review Medicines Use Reviews (MURs) A “concordance” based review between patients and an accredited pharmacist Establishes picture of use of medicines Chance to identify Poor/ineffective use of medicines (Rx and OTC) Side effects Interactions Potential cost savings Lifestyle interventions ‘MEDICINES CHECK-UP’ 19/09/2018

Medicines Use Review NOT a clinical review No access to patient notes Not a full discussion of conditions Chance to improve Patient care Patients’ experience of taking medicines Relationships with GPs Job satisfaction 19/09/2018

MUR – an example Mrs Ida Bray Spend 5 minutes reading the patient details and prescribing history section of your handout: Current prescription Patient Medication Record Repeat prescription Consider Likely conditions What are the main issues you would like to ask the patient about for each drug. 19/09/2018

MUR Case study 19/09/2018

Consent and patient details 19/09/2018

Patient information 19/09/2018

MUR procedure 19/09/2018

Aspirin issues 19/09/2018

Ferrous sulphate issues 19/09/2018

Furosemide issues 19/09/2018

Istin issues 19/09/2018

Co-codamol issues 19/09/2018

Summary of conversation on MUR form 19/09/2018

Other questions to ask 19/09/2018

What recommendations could be made? 19/09/2018

What recommendations could be made? 19/09/2018

Recommendations on last page of MUR form – go to GP 19/09/2018

The final stages 19/09/2018

By the way…… 19/09/2018

MURs in 2012 At least 50% of all MURs undertaken in a year (01 April – 31 March) must be on patients who fall within one of the national target groups. There are three national target groups which are: Patients taking high risk medicines High risk medicines are those listed in the following British National Formulary (BNF) sections:- NSAIDs Anticoagulants (including low molecular weight heparin) Antiplatelets Diuretics 19/09/2018

MURs in 2012 Patients recently discharged from hospital This group covers patients recently discharged from hospital who had changes made to their medicines while they were in hospital. Ideally patients discharged from hospital will receive an MUR within four weeks of discharge but it is recognised that this might not always be practical so the MUR can take place up to eight weeks after discharge. A registered pharmacist should use their professional judgement to determine where a patient will benefit from such an MUR more than four weeks after discharge from hospital. 19/09/2018

MURs in 2012 Patients prescribed certain respiratory medicines This group covers patients taking a respiratory medicine included in the following BNF subsections: Adrenoceptor agonists Antimuscarinic bronchodilators Theophylline Compound bronchodilator preparations Corticosteroids Cromoglicate and related therapy, leukotriene receptor antagonists and phosphodiesterase type-4 inhibitors 19/09/2018

New Medicines Service (NMS) Four conditions/therapy areas were selected to be included in the initial rollout of the NMS. These are: asthma and COPD type 2 diabetes antiplatelet/anticoagulant therapy Hypertension 19/09/2018

Make sure you read the service spec before providing NMS! 19/09/2018

NMS intervention 19/09/2018

NMS intervention 19/09/2018

NMS follow-up 19/09/2018

NMS follow-up 19/09/2018

Evaluation of NMS 19/09/2018