1. S Medicine Use Reviews NSAIDs NHS Specialist Pharmacy Services Medicines Use & Safety P S East & South East England Specialist Pharmacy Services East of England, London, South Central & South East Coast Medicines Use and Safety ©East & South East England Specialist Pharmacy Services

2. S Introduction and welcome Housekeeping - Fire drills - Facilities - Refreshments P S Medicines Use and Safety

3. S Programme Objectives and warm up Expert presentation Activity one Activity two Presentation two NSAID MUR project presentation Activity three P S Medicines Use and Safety

4. S Objectives To revise and update your knowledge of NSAID efficacy and safety problems To develop communication and clinical skills to enhance the NSAID targeted MURs To understand how NSAID MURs have been used to improve NSAID safety To improve outcomes for patients taking NSAIDs To increase the number and efficacy of NSAID targeted MURs locally P S Medicines Use and Safety

5. S Warm-up Write down on a sticky note a number from 1-10 where 1 is not confident in doing MURs and 10 is very confident What is the biggest barrier for you doing MURs? P S Medicines Use and Safety

6. S Key facts quiz 10 questions 10-15 seconds to discuss each answer in your groups P S Medicines Use and Safety

7. S Question 1 Are COX2 selective inhibitors more effective than traditional NSAIDs? P S Medicines Use and Safety

8. S Answer to question 1 Are COX2 selective inhibitors more effective than traditional NSAIDs? NO Similar efficacy to traditional NSAIDs such as diclofenac and naproxen P S Medicines Use and Safety

9. S Question 2 Does NICE guidance on osteoarthritis recommend use of topical NSAIDs? P S Medicines Use and Safety

10. S Answer to question 2 Does NICE guidance on osteoarthritis recommend use of topical NSAIDs? YES Like paracetamol, these should be considered before oral NSAIDs P S Medicines Use and Safety

11. S Question 3 Can ranitidine be used to prevent NSAID induced ulcers? P S Medicines Use and Safety

12. S Answer to question 3 Can ranitidine be used to prevent NSAID induced ulcers? YES But standard doses are not effective and PPIs are preferred P S Medicines Use and Safety

13. S Question 4 Can misoprostol be used to prevent NSAID induced ulcers? P S Medicines Use and Safety

14. S Answer to question 4 Can misoprostol be used to prevent NSAID induced ulcers? YES But misoprostol tends to be poorly tolerated P S Medicines Use and Safety

15. S Question 5 Should OTC ompeprazole be used to prevent NSAID induced ulcers? P S Medicines Use and Safety

16. S Answer to question 5 Should OTC omeprazole be used to prevent NSAID induced ulcers? NO OTC omeprazole is only licensed for heartburn and acid reflux P S Medicines Use and Safety

17. S Question 6 Should exercise be a core treatment for people with osteoarthritis, regardless of age and pain severity? P S Medicines Use and Safety

18. S Answer to question 6 Should exercise be a core treatment for people with osteoarthritis, regardless of age and pain severity? YES NICE advises exercise for all (irrespective of age, co morbidity, pain or disability) and weight loss if overweight or obese P S Medicines Use and Safety

19. S Question 7 Does NICE recommend using glucosamine in treatment of osteoarthritis? P S Medicines Use and Safety

20. S Answer to question 7 Does NICE recommend using glucosamine in treatment of osteoarthritis? NO The use of glucosamine or chondroitin products is not recommended for the treatment of osteoarthritis. Rubefacients are not recommended either. P S Medicines Use and Safety

21. S Question 8 Has use of naproxen increased because it has fewer GI adverse effects than other NSAIDs (eg diclofenac)? P S Medicines Use and Safety

22. S Answer to question 8 Has use of naproxen increased because it has fewer GI adverse effects than other NSAIDs (eg diclofenac)? NO Use has increased but this is because it appears to have lower cardiovascular risk than other NSAIDs, not lower GI risk. P S Medicines Use and Safety

23. S Question 9 Can NSAIDs be taken with methotrexate? P S Medicines Use and Safety

24. S Answer to question 9 Can NSAIDs be taken with methotrexate? Yes But NSAIDs reduce excretion of methotrexate so increase the toxicity. The dose of methotrexate needs to be carefully monitored and OTC NSAIDs avoided P S Medicines Use and Safety

25. S Question 10 Is OTC diclofenac 12.5mg a useful product? P S Medicines Use and Safety

26. S Answer to question 10 Is OTC diclofenac 12.5mg a useful product? ? This is a conundrum!! P S Medicines Use and Safety

27. S Expert presentation P S Medicines Use and Safety

28. S Activity One - Patients In your groups discuss the following: - What would make you feel more confident to do MURs? -What systems do you have in place to sign up people for MURs? -Share the ways you recruit reluctant patients (preworkshop activity) P S Medicines Use and Safety

29. S Activity Two - Prescribers In your groups, discuss whether or not you get feedback from GPs after doing MURs If not, think about how they might get this Share hints and tips about good ways of linking with GP surgeries P S Medicines Use and Safety

30. S Presentation NSAID MUR project P S Medicines Use and Safety

31. S Medicines related hospital admissions 6% of admissions due to problems with medicines Mostly preventable Most commonly NSAIDs, diuretics, anticoagulants and antiplatelets Howard et al Qual Saf Health Care 2003;12:280-285 P S Medicines Use and Safety

32. S Principles for MUR high risk drugs list Type of harm could be prevented by an MUR and the pharmacist will have the skills, knowledge and information to deliver it’ P S Medicines Use and Safety

33. S NSAIDs and preventable admissions LACK OF MONITORING Renal necrosis PRESCRIBING ISSUES GI bleed – 2+ risk factors no GI prophylaxis ADHERENCE ISSUES GI bleed - not taking GI prophylaxis GI bleed - self-medicating with OTC NSAIDs P S Medicines Use and Safety

34. S NSAIDs Widely used Effective anti-inflammatory and analgesic Adverse effects include - Renal - Cardiovascular - Gastro intestinal P S Medicines Use and Safety

35. S GI safety ‘Each year NSAIDs cause about 3,500 hospitalisations for, and 400 deaths from, ulcer bleeding in people aged 60 years or above.’ Drug & Therapeutics Bulletin Feb 2011 P S Medicines Use and Safety

36. S GI Safety PPI not prescribed - NICE guidance on OA, RA and people over 45 with chronic low back pain - GI prophylaxis with a PPI should be co-prescribed for all NSAID and COX2 patients PPI not taken Two NSAIDs taken concurrently - OTC as well as prescribed NSAID P S Medicines Use and Safety

37. S Isn’t NSAID safety fixed already? Survey of 100 MURs 2009-2010 11 patients on NSAIDS 4 regular NSAID patients aged over 55 with no GI protection Local pharmacy snapshot December 2010 25 patients on regular NSAIDs 5 aged over 55 with no GI protection 4 not regularly collecting PPI OA patient survey 2011 43% not offered GI prophylaxis P S Medicines Use and Safety

38. S Business case Put together in summer 2010 Support from CCG, PCT, LPC Information to all local GPs and CPs Educational grant from Pfizer P S Medicines Use and Safety

39. S The NSAID MUR Regular prescription for NSAID Focus GI safety PLUS preventing concomitant use of two NSAIDs from any outlet Two patient groups taking NSAIDs 1.Inadequate GI prophylaxis 2.Over 55s P S Medicines Use and Safety

40. S Data collection Smart-survey.co.uk or paper copy Show NSAID MURs being done Demonstrate value i.e. preventing adverse events and admissions P S Medicines Use and Safety

41. S Results 17 pharmacies involved (all types) 15 months (Jan 11 – Mar 12) 142 patients (Mean age 64) - 1% prescribed two NSAIDs - 8% patients taking OTC and prescribed NSAID - 3% patients taking other GI risk drugs P S Medicines Use and Safety

42. S Inadequate GI prophylaxis Four non-adherent to GI prophylaxis 82 no GI prophylaxis Collected follow up data on 48 patients - 23 (48%) GI prophylaxis started - 7 (15%) NSAID stopped - 4 (8%) reduced/less frequent NSAID dose - 8 (17%) prescriber/patient active decision not to change - 6 (12%) no change P S Medicines Use and Safety

43. S Examples 91 year old lady prescribed two NSAIDs, low dose aspirin but no PPI Patient stopped taking lansoprazole because of upset stomach, prescriber was unaware 85 year old lady on ibuprofen referred to GP re GI risk, prescribed omeprazole P S Medicines Use and Safety

44. S Overview of results NSAID MURS 63% had NSAID safety issue identified 7% improved safety during MUR (e.g. OTC NSAIDs identified or non-adherence to prophylaxis) Post MUR follow-up of GI safety 71% changed to improve safety P S Medicines Use and Safety

45. S 17 million NSAID Rx in England each year…. P S Medicines Use and Safety

46. S Activity Three – preworkshop task In your groups discuss your pre-workshop activity: Did you manage to find three patients with regular NSAIDs? Any of these over 75? Any of these with no gastro-protection? Have you done an MUR on any of these patients? P S Medicines Use and Safety

47. S Activity Four – Case Studies In your groups discuss the three vignettes You only have about 3-4 minutes for each one Feedback at the end P S Medicines Use and Safety

48. S Action plan Do you feel more confident? What are you going to do as a result of this learning? - Tomorrow or as soon as you return to work - Within a few weeks - Within a longer period (may involve further learning or accreditation) P S Medicines Use and Safety

49. S Reminder of Objectives To revise and update your knowledge of NSAID efficacy and safety problems To develop communication and clinical skills to enhance the NSAID targeted MURs To understand how NSAID MURs have been used to improve NSAID safety To improve outcomes for patients taking NSAIDs To increase the number and efficacy of NSAID targeted MURs locally P S Medicines Use and Safety