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

2. East & South East England Specialist Pharmacy Services Introduction and welcome Housekeeping –Fire drills –Facilities –Refreshments

3. East & South East England Specialist Pharmacy Services Programme Objectives and warm-up Expert presentation Activities NSAID MUR project presentation Activities Action plan and close

4. East & South East England Specialist Pharmacy Services 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

5. East & South East England Specialist Pharmacy Services 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?

6. East & South East England Specialist Pharmacy Services Key facts quiz 10 questions 10-15 seconds to discuss each answer in your groups

7. East & South East England Specialist Pharmacy Services Question 1 Are COX-2 selective inhibitors more effective than traditional NSAIDs?

8. East & South East England Specialist Pharmacy Services Answer to question 1 Are COX-2 selective inhibitors more effective than traditional NSAIDs? NO Similar efficacy to traditional NSAIDs such as diclofenac and naproxen.

9. East & South East England Specialist Pharmacy Services Question 2 Does NICE guidance on osteoarthritis recommend use of topical NSAIDs?

10. East & South East England Specialist Pharmacy Services Answer to question 2 Does NICE guidance on osteoarthritis recommend use of topical NSAIDs? YES Like paracetamol, these should be considered before oral NSAIDs.

11. East & South East England Specialist Pharmacy Services Question 3 Can ranitidine be used to prevent NSAID-induced ulcers?

12. East & South East England Specialist Pharmacy Services Answer to question 3 Can ranitidine be used to prevent NSAID-induced ulcers? YES But standard doses are not effective and PPIs are preferred.

13. East & South East England Specialist Pharmacy Services Question 4 Can misoprostol be used to prevent NSAID-induced ulcers?

14. East & South East England Specialist Pharmacy Services Answer to question 4 Can misoprostol be used to prevent NSAID-induced ulcers? YES But misoprostol tends to be poorly tolerated.

15. East & South East England Specialist Pharmacy Services Question 5 Should OTC omeprazole be used to prevent NSAID-induced ulcers?

16. East & South East England Specialist Pharmacy Services 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.

17. East & South East England Specialist Pharmacy Services Question 6 Should exercise be a core treatment for people with osteoarthritis, regardless of age and pain severity?

18. East & South East England Specialist Pharmacy Services 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.

19. East & South East England Specialist Pharmacy Services Question 7 Does NICE recommend using glucosamine in treatment of osteoarthritis?

20. East & South East England Specialist Pharmacy Services 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.

21. East & South East England Specialist Pharmacy Services Question 8 Has use of naproxen increased because it has fewer GI adverse effects than other NSAIDs (eg diclofenac)?

22. East & South East England Specialist Pharmacy Services 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.

23. East & South East England Specialist Pharmacy Services Question 9 Can NSAIDs be taken with methotrexate?

24. East & South East England Specialist Pharmacy Services 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.

25. East & South East England Specialist Pharmacy Services Question 10 Is OTC diclofenac 12.5mg a useful product?

26. East & South East England Specialist Pharmacy Services Answer to question 10 Is OTC diclofenac 12.5mg a useful product? ? The MHRA is consulting on whether to make POM again!

27. East & South East England Specialist Pharmacy Services Expert presentation

28. East & South East England Specialist Pharmacy Services 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 (pre-workshop activity).

29. East & South East England Specialist Pharmacy Services Activity two - prescribers In your groups, discuss whether or not you get feedback from GPs after doing MURs. If not, think about how you might get this. Share hints and tips about good ways of linking with GP surgeries.

30. East & South East England Specialist Pharmacy Services East of England, London, South Central & South East Coast Presentation NSAID MUR project

31. East & South East England Specialist Pharmacy Services Medicines-related hospital admissions 6% of admissions due to problems with medicines Mostly preventable Most commonly NSAIDs, diuretics, anticoagulants and antiplatelets Howard R L et al. Quality and Safety in Health Care 2003;12: 280-285.

32. East & South East England Specialist Pharmacy Services 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.’ http://psnc.org.uk/services-commissioning/advanced- services/murs/national-target-groups-for-murs

33. East & South East England Specialist Pharmacy Services NSAIDs and preventable admissions LACK OF MONITORING –Renal necrosis PRESCRIBING ISSUES –GI bleed – 2+ risk factors no GI prophylaxis prescribed ADHERENCE ISSUES –GI bleed - not taking GI prophylaxis –GI bleed - self-medicating with OTC NSAIDs

34. East & South East England Specialist Pharmacy Services 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

35. East & South East England Specialist Pharmacy Services Business case Put together in summer 2010 Support from CCG, PCT, LPC Information to all local GPs and CPs Educational grant from Pfizer

36. East & South East England Specialist Pharmacy Services The NSAID MUR Regular prescription for NSAID Focus GI safety Two patient groups at particular risk of NSAID adverse events: 1.Inadequate GI prophylaxis 2.Over 55s

37. East & South East England Specialist Pharmacy Services Data collection Smart-survey.co.uk or paper copy Show NSAID MURs being done Demonstrate value i.e. preventing adverse events and admissions

38. East & South East England Specialist Pharmacy Services 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 NSAIDs –3% patients taking other GI risk drugs

39. East & South East England Specialist Pharmacy Services Inadequate GI prophylaxis 4 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

40. East & South East England Specialist Pharmacy Services 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 regarding GI risk, prescribed omeprazole.

41. East & South East England Specialist Pharmacy Services Overview of results NSAID MURS 63% had NSAID safety issue identified 7% improved safety during MUR (eg, OTC NSAIDs identified or non-adherence to prophylaxis) Post MUR follow-up of GI safety 71% changed to improve safety Livingstone C, Patel C J, Sinha R and Greensmith S. Evaluation of targeted MURs in preventing avoidable harm from NSAIDs. IJPP 2012;20(2): 71.

42. East & South East England Specialist Pharmacy Services 17 million NSAIDs prescriptions in England each year….

43. East & South East England Specialist Pharmacy Services Activity three – your NSAID patients 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?

44. East & South East England Specialist Pharmacy Services 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.

45. East & South East England Specialist Pharmacy Services NSAID audit NSAID safety clinical audit templateNSAID safety clinical audit template Available to downloadAvailable to download Use it to meet the contract requirementsUse it to meet the contract requirements

46. East & South East England Specialist Pharmacy Services 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)*

47. East & South East England Specialist Pharmacy Services 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

48. East & South East England Specialist Pharmacy Services Thank you Safe journey home