Prescribing and QiPP 2011
Anne-Marie Bailey
Associate Lead for Medicines
Management
NHS south of Tyne & Wear
QiPP
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Quality
Innovation
Productivity
Prevention
How will this be achieved?
4 key regional programmes:
• Efficient use of medicines
• Repeat medication management – supporting
patients
• Procurement
• Local Decision-Making – Effective
Commissioning
Local Decision Making
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Area Prescribing Committee
Joint committee between PCT and FT
Regional decision making
NETAG (North East Treatment Approvals Group)
NECDAG (North East Cancer Drugs Approval
Group)
• Formulary development
Formulary Development
• Seamless care
• Familiarity with drugs
• Cost-effective prescribing
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Safety
Tolerability
Effectiveness
Price
Traffic Light System
• RED = hospital prescribing only
• AMBER = shared care
– Should be started in hospital
– Can be handed over to primary care with appropriate
documentation
• GREEN PLUS = started in secondary care, less
specialised monitoring etc needed
• GREEN = can be started in primary care
Dabigitran and Non-valvular Atrial Fibrillation
• NETAG review in June 2011
• Warfarin will remain first line treatment for AF
• Dabigatran can be considered for patients with an allergy
or absolute contra-indication to warfarin
• Cost impact currently being evaluated to extend
Dabigitran to patients who are not adequately treated on
warfarin or whose INR is unstable
• A bleeding risk that would lead to a contra-indication
to warfarin would also contra-indicate to Dabigatran
• Dabigatran should be specialist initiated at present
QIPP – current work
Gaviscon Advance
Doxazosin MR
Prednisolone EC
Escitalopram
Diclofenac (oral)
Diclofenac (topical)
Venlafaxine MR
Famciclovir 750mg 1 daily
Peptac
Doxazosin
Prednisolone
Citalopram (or sertraline)
Naproxen
Piroxicam
Venlafaxine standard
Aciclovir 800mg 5x daily
Prescribing Terminology
ASTRO-PUs
Age Sex Temporary Resident Originated Prescribing Units
STAR-PUs
Specific Therapeutic Group Age-Sex Related Prescribing Units
ADQ
Average Daily Quantity
NIC
Net Ingredient Cost
PPI Prescribing
Prices for 28 doses from Drug Tariff, September 2011
• Esomeprazole:
– 20mg tablets
– 40mg tablets
£18.50
£25.19
• Lansoprazole:
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15mg capsules
30mg capsules
15mg FasTabsTM
30mg FasTabsTM
£1.22
£1.89
£2.99
£5.50
• Pantoprazole:
– 20mg tablets
– 40mg tablets
£1.34
£2.08
• Rabeprazole:
– 10mg tablets
– 20mg tablets
£11.56
£19.55
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56 =
£3.24
<half
cost
Omeprazole:
– 10mg capsules
– 20mg capsules
– 40mg capsules
– 10mg MUPSTM tablets
– 20mg MUPSTM tablets
– 40mg MUPSTM tablets
– 10mg tablets
– 20mg tablets
– 40mg tablets
£1.57
£1.62
£6.68
£7.75
£11.60
£23.20
£5.63
£5.17
£25.12
Statins summary
• Simvastatin = first-line
• Simvastatin or pravastatin ONLY in primary
prevention
• No targets for primary prevention
• Atorvastatin 80mg is being used in ACS
• Ezetimibe – only if all statins not tolerated
• Familial Hypercholesterolaemia – specialist
referral
NICE guidance: ACE inhibitors first-line
NICE CG34 Hypertension, 2006; NICE CG5 Heart Failure, 2003;
NICE CG48 MI: secondary prevention, 2007; NICE CG87 Type 2 diabetes, 2009;
NICE CG73 Chronic kidney disease, 2008
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No evidence that A2RAs are superior to ACE inhibitors
No evidence that A2RAs are safer than ACE inhibitors
A2RAs do not reduce risk of MI vs. placebo
A2RAs cause less cough than ACE inhibitors but
difference is small (absolute difference in discontinuation
due to cough 3% in ONTARGET)
• Generic ACE inhibitors are less expensive than A2RAs
• Possible increase in fatal CV events with Olmesartan
Clopidogrel generic prescribing
• Clopidogrel 75mg
• Plavix 75mg
• Clopidogrel Hydrogen
Sulphate 75mg
Cost for 30 tablets
• £2.41
• £35.64
• £35.64
Hypoglycaemic Agents
1st line Metformin: 2nd line Sulphonylureas
• Metformin – only hypoglycemic agent to reduce total
mortality, diabetes related deaths and CV events
(Mortality NNT 14 over 10.7yrs UKPDS)
• Sulphonylureas can be used first line if significant
osmotic symptoms and a rapid response is needed.
• Small increased risk of bladder cancer with Pioglitazone
(ARI 0.08% NNH 1250)
• Increase risk of heart failure (NNH 62 over 3 years) and
fractures with glitazones (NNH 55 for 1 yr in women
average age of 56)
• No long term safety data for gliptins or GLP-1s
• Reports of pancreatitis and acute renal failure with GLP1s
Insulin analogues
NICE CG 87 May 2009
• Long acting Insulin analogues should be reserved for
patients with:– Problematic hypoglycaemia
– Require assistance to administer and monitor their injections
• NPH insulins are preferred insulin (Insulatard, Insuman
basal and Insulin I)
• Reviews of studies comparing insulin analogues with
standard non analogue insulins found no major clinical
differences
• Long term safety of insulin analogues is unknown
• Analogues are 1.7-1.8 times more expensive than
standard insulin
Cephalosporin & Quinolone Prescribing
• Regionally, second and third generation cephalosporins
and clindamycin are restricted to reduce the risk of
MRSA and C.difficile
• Quinolones and cephalosporins should be reserved to
treat resistant disease
• Avoid cephalosporins or quinolones in patients at high
risk of HCAIs – over 65’s, LTCs requiring recurrent
antibiotics, recent hospital admission, institutionalised
• Quinolones are recommended first line by the HPA only
in limited situations (e.g. acute pyelonephritis or acute
prostatitis)
“Safer NSAIDs”
• Naproxen
• Ibuprofen ≤ 1200mg daily
Review patients:
• Over 65 years of age
• With CVD, PVD, Heart failure and diabetes
• With hypertension
• Active or history of Peptic Ulcer Disease
Generic Alendronate and % Alendronate as a proportion of
bisphosphonates
1st line
• Alendronic Acid 10mg
• Alendronic Acid 70mg
2nd line
• Risedronate 5mg
• Risedronate 35mg
3rd line
• Strontium Ranelate
• Denosumab Inj
Cost for 28 days
• £1.56
• £1.16 (Branded £22.80)
• £17.54
• £2.20 (Branded £19.12)
• £27.08
• £28.47 (not inc. admin
costs)
NICE Guidance: Bisphosphonates first line
NICE TA 160: October 2008. NICE TA 161: October 2008:
NICE TA 204: June 2011
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First line Alendronic Acid
Second line Risedronate
Third line Strontium Ranelate or Denosumab
No difference in the risk of serious upper GI
reactions has been demonstrated between
alendronic acid and risedronate
Figure 8a: North East PCTs - Weighted Schedule 4 CD benzodiazepine prescribing frequency April 2007 to March 2011
1100
1000
County Durham
Darlington
Gateshead
ADQ/DDD per 1000 patients
900
Hartlepool
Middlesbrough
Newcastle
800
North Tyneside
Northumberland Care Trust
Redcar & Cleveland
700
South Tyneside
Stockton-on-Tees Teaching
Sunderland Teaching
600
North East
North of England
England
500
400
0708Q1 0708Q2 0708Q3 0708Q4 0809Q1 0809Q2 0809Q3 0809Q4 0910Q1 0910Q2 0910Q3 0910Q4 1011Q1 1011Q2 1011Q3 1011Q4
Benzodiazepines prescribing
• If prescriptions are issued, they are short term, small
quantities and controlled
• Newly registered patients are not issued with
prescription until reviewed by GP they are then strongly
encouraged to withdraw
• Practice policy for “troublesome patients” – lost
prescriptions, lost medication, left at relatives, eaten by
the dog……
• Blanket no prescribing of z drugs
• Avoid dual prescribing of benzodiazepines e.g.
Diazepam and Temazepam’
• Consider using other alternative drugs for anxiety,
depression, chronic pain
Street prices (2010)
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Diazepam 2mg (whites)
Diazepam 5mg (yellows)
Diazepam 10mg (blues)
Temazepam 10mg (wobbly)
Zopiclone 7.5mg
Amitriptyline 1 sm strip
(tripline)
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25p
50p
£1
£1
£2
£1
Other drugs associated with diversion
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Dihydrocodeine
Tramadol
Codeine
Gabapentin
Pregabalin
Methadone & Buprenorphine
Methylphenidate
Dexamfetamine
Wound management and sip feeds
• Formularies have been developed in most PCOs
across the SHA region
• Exploring option of procurement of dressings
and sip feeds on contract and other “off
prescription” routes of supply
• Department of health are looking to devolve
budgets to provider services
Specials
• Prescribe a licensed medicine first-line
– ALWAYS
• Licensed liquid may be more expensive than
crushing tablet option
– NOT NEGOTIABLE
• Crushing tablet is unlicensed BUT
• So is a special (unlicensed liquid)
• RPS guidance available
Specials
• Quetiapine 12.5mg/5ml for swallowing difficulties
– £299.32 for 1120ml
– OR tablets can be crushed and mixed with water
(£33.83 for 60 x 25mg)
• or alternative drugs have liquid options: amisulpiride,
risperidone, olanzapine (oro-disp) and aripiprazole (oro-disp)
Anti-Dementia Drugs – Off Patent Formulations
• Rivastigmine is now off patent, Donepezil in
January 2012 and Galantamine in Summer 2012
• New novel formulations now being introduced
which are more costly – Galantamine MR,
Rivastigmine patches and Donepezil
orodispersible tablets
• Regionally, MMTs are working with Acute and
Mental Health Trusts to ensure cost growth is
contained by remaining with the older
formulations
CD e-learning
http://www.npc.nhs.uk/controlled_drugs/less_than_sixty.php
• Controlled drugs e-learning available for
practices (25 min PowerPoint presentation)
• Presentation covers all aspects of controlled
drugs management from ordering through to
destruction and prescribing
• Useful for:– practices who store CDs
– individual GPs holding CDs in doctors bag
– GP registrars or new GPs to the practice
Safety issues
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Aspirin and reduction in cancer risk
Implanon and contraceptive failure
NPSA safer use of insulin alert
Inhaled corticosteroids and risk of diabetes
Olmesartan and possible increased risk of CV
death
• Mixing of medicines (syringe drivers and
nebules)
• NPSA patient passports – Lithium, insulin and
warfarin
Useful links
• Gateshead Information Network (GIN)
– www.gin.sotw.nhs.uk
• National Prescribing Centre (NPC)
– www.npc.co.uk (Therapeutics)
• Electronic Medicines Compendium
– www.medicines.org.uk
Any Questions?
