Targeted MURs for patients on NSAIDs

By Carina Livingstone

For the pharmacy profession, reducing the number of preventable Saturn Stills/SPlmedicines-related admissions is a clear patient safety challenge. About 4 per cent of hospital admissions are reported to be drug-related and potentially preventable.1 Four drug classes — antiplatelets, diuretics, non steroidal anti-inflammatory drugs and anticoagulants — account for about half of these admissions and this is reflected in the high-risk drug targeted medicines use review service in England.

Why NSAIDs?

Gastrointestinal toxicity causes a significant number of admissions for patients taking NSAIDs. Causes include:

  • Patients not taking prescribed gastroprotection
  • NSAIDs being prescribed without appropriate gastroprotection
  • Patients self-medicating with NSAIDs despite a history of gastrointestinal bleeds2


Renal admissions have also been reported (due to inadequate renal monitoring) and, in recent years, concerns about NSAIDs causing thrombotic events, many of which may be preventable, have come to the fore.

To give an example of figures and costs, data for South East Coast Strategic Health Authority showed 49 NSAID-related hospital admissions in December 2009, each costing an average of £3,000. However, these figures are likely to be an underestimate because coding depends on accurate identification and documentation of NSAIDs as a likely cause of admissions in patient records. In 2000, it was estimated that NSAIDs cause 50 mostly avoidable admissions per year per 100,000.3 Extrapolating for the south east coast population (4.2 million) the annual figure would be about 2,100 (174 per month).

The cost of managing bleeds may also be greater than expected, with the actual cost of managing a bleeding or perforated ulcer attributable to an NSAID estimated at £6,825.4 Clearly such emergency hospital admissions are a rare but awful consequence of NSAID use, both for the patient and the health economy.

Current National Institute for Health and Clinical Excellence guidance for both osteoarthritis and rheumatoid arthritis recommends that a proton pump inhibitor is co-prescribed with standard oral NSAIDs or  cyclo-oxygenase-2 inhibitors. And, according to Clinical Knowledge Summaries, gastroprotection is advised for regular users of both traditional oral NSAIDs and coxibs (see Panel 1). However, consumer research sponsored by the pharmaceutical industry has suggested that more than 40 per cent of patients with osteoarthritis who take NSAIDs are not offered gastroprotection. To find out more about the situation in the south east, two pharmacies collected prescription information for two weeks in December 2010. Of 25 patients prescribed regular NSAIDs, five aged over 55 years had no gastroprotection prescribed and four others were not regularly collecting a gastroprotective agent. An MUR survey in 2009/10, which included 11 patients prescribed NSAIDs, found four regular NSAID users aged over 55 years were not co-prescribed gastroprotection.

 Panel 1: gastroprotection – Background information*

NSAIDs inhibit cyclo-oxygenase enzymes. COX-1 produces prostaglandins that help maintain gastric mucosal integrity, and COX-2 produces prostaglandins that mediate pain and inflammation.

At risk groups

People at high risk of NSAID-induced gastrointestinal effects include those:

  • Aged 65 years or older
  • With a history of gastroduodenal ulcer, gastrointestinal bleeding or gastroduodenal perforation
  • Taking medicines known to increase the risk of gastrointestinal toxicity (eg, anticoagulants, low-dose aspirin, corticosteroids, selective serotonin reuptake inhibitors, venlafaxine, duloxetine)
  • With serious comorbidity (eg, cardiovascular disease, hepatic or renal impairment, diabetes, hypertension)
  • Needing to use NSAIDs for prolonged periods (eg, people with osteoarthritis or rheumatoid arthritis, people 45 years of age or over with chronic lower back pain)
  • Using the maximum recommended dose of an NSAID

Additional risk factors include the NSAID used, the presence of Helicobacter pylori infection, excessive alcohol use and heavy smoking.

Gastroprotection

Gastroprotective agents include proton pump inhibitors, histamine 2 antagonists and prostglandin analogues (eg, misoprostol).
PPIs are effective at reducing the risk of NSAID–induced endoscopic gastric and duodenal ulcers, and are well tolerated. Standard doses of H2-receptor antagonist, however, are not very effective in reducing the risk of these ulcers. Misoprostol is the only prophylactic drug that has been shown to reduce the occurrence of clinically important ulcer complications, but is associated with significant adverse effects and poor compliance.
Although concerns have been expressed about adverse effects of PPIs, co-prescription of a PPI with an NSAID is currently advocated in national guidelines.


* Adapted from Clinical Knowledge Summaries (www.cks.nhs.uk)

 

 What we did in Crawley

Problems with patients self-medicating and poor compliance with gastroprotection stand out as aspects that could be effectively addressed in community pharmacy. Based on our background research, specialist pharmacy services developed the rationale and business case for NSAID-targeted MURs and led a local implementation project. The work also supports the QIPP agenda, focusing on service quality, utilising existing resources and preventing harm from medicines.

A local commissioning consortium in Crawley was keen to trial some targeted MURs as a means of ensuring maximum patient benefit from the service and, potentially, of avoiding admissions. Specialist pharmacy services, working with a pharmacist member of the consortium board, the local pharmaceutical committee, the prescribing lead and primary care trust medicines management staff, obtained agreement from all the GP practices in the group for an NSAID-targeted MURs focusing on ensuring gastrointestinal safety. A pharmacy in Portsmouth was also keen to take part and had similar support from local GPs and the PCT. The project was launched at the end of January 2011.

Two groups of patients regularly collecting prescriptions for oral NSAIDs, including coxibs, for at least three months were identified for the service:

  1. Patients of any age either not prescribed or not collecting a gastroprotective agent
  2. All patients aged over 55 years (because the risks of adverse events increases with age)

For patients in group 1, it was agreed that initially a prescription intervention MUR would be carried out, then a follow-up MUR could be provided one to three months later to confirm what action had been taken.

The MURs focused on gastroprotection and use of over-the-counter painkillers. Although renal and cardiovascular adverse effects are also significant, they are more difficult to address in an MUR because they tend to involve factors such as inadequate monitoring and drug choice.

Tips for pharmacists performing NSAID-targeted MURs are given in Panel 2.

 Panel 2: What you could find out

 

Does the patient know why they are using the medicine?

Explore the patient’s understanding of the purpose of NSAID treatment. Is the NSAID being taken for general pain relief, muscle pain, osteoarthritis, headache or gout? It is useful to find out if the patient is being managed by a specialist or if there is any specialist recommendation for a regular or high-dose NSAID (eg, patients with rheumatoid arthritis or ankylosing spondylitis).

Does the patient use the medicine as prescribed?

 

It can be useful to ask what dose the patient takes and how often. It is also revealing to ask how effective the patient finds the medicine. Generally, patients should take the lowest effective dose of NSAID for the shortest possible time. You might ask if the patient could manage his or her symptoms with occasional use rather than regular use or with a lower dose.

Are side effects reported?

 

Be specific. Ask patients if they ever have bad indigestion or stomach ulcer problems. Refer patients at high risk (Panel 1) who are not prescribed a gastroprotective agent and, for those who are prescribed one, reinforce the importance of taking it to prevent stomach problems. Other pain relief or non-drug interventions may well be preferable to using NSAIDs for some patients.

Pharmacists can also advise on smoking cessation and alcohol consumption where appropriate because heavy smokers and drinkers are at increased risk of gastrointestinal problems.

For older patients, particularly those over 70, the prescriber needs to ensure that renal function is not compromised. To support this, pharmacists might ask patients if they remember having any blood tests in the past two years. If not, this could be noted on the MUR form.

Does the patient take over-the-counter medicines?

 

Unwittingly taking two NSAIDs has resulted in serious harm. Check whether the patient uses any OTC products. Explain that it is important not to buy any painkillers without checking with a pharmacist.

 

Can these MURs make a difference?

 

A simple survey was designed to collect data about the uptake and outcome of the NSAID MURs. The project involves 22 pharmacies and, by September, 14 were contributing, with 62 NSAID patient reports. The average patient age was 63 years (range 33–90 years) and most (52/62) were in group 1.

Two patients were identified as having poor adherence to a PPI and 50 had no gastroprotection prescribed. Most of the latter group were referred to the prescriber to

review the continued need for NSAID treatment or co-prescription of a PPI where appropriate. Panel 3 gives example cases. Several follow-up MURs for patients in group 1 have now been reported where a PPI has been initiated and adherence discussed. We will continue to recruit and follow up at least 100 patients.

 Panel 3: Cases

  •  A 66-year-old on diclofenac (changing to naproxen) prescribed omeprazole but not taking it because of side effects was referred for an alternative.
  • A 77-year-old on etoricoxib and no gastroprotection was referred for gastroprotection and renal function monitoring.
  • A 76-year-old was being prescribed diclofenac and lansoprazole. The lansoprazole was collected regularly and adherence confirmed. Use of OTC pain killers was discussed.
  • A 90-year-old was being prescribed ibuprofen and meloxicam with no gastroprotection. The need for both NSAIDs was queried with the GP and a PPI letter sent.

Although it is unlikely that a reduction in hospital admissions for NSAID-related gastrointestinal bleeds can be identified within this time frame and sample size, it will be possible to estimate the potential number of bleeds prevented based on patient demographics had NSAID use continued with inadequate gastroprotection. Such evidence is vital to demonstrate service value.

Not just community pharmacy

 

The National Prescribing Centre has been leading on safe use of NSAIDs, particularly in primary care, for a number of years. For primary care there are performance indicators aimed at reducing total NSAID use and increasing the proportion of ibuprofen or naproxen prescribed in order to minimise cardiovascular risk. In England, ibuprofen and naproxen currently account for about 50 per cent of all NSAIDs prescribed in primary care but this is often not reflected in acute trusts, where diclofenac can account for well over 60 per cent. We now need to ensure that NSAID safety initiatives are in place across all healthcare settings, from community pharmacy, primary care and GP out-of-hours, to hospital, community and ambulance trusts.

 

Resources

  • Information on management of analgesia for and for NSAIDs is available at www.cks.nhs.uk.
  • Information on the cardiovascular and gastrointestinal safety of NSAIDs (MeReC Extra, issue 30) is available at www.npc.nhs. uk.

References

  1. Howard RL, Avery AJ, Salvenburg S, Royal S, Pipe G, Lucassen P, Pirmohamed M. Which drugs cause preventable admissions to hospital? A systematic review. Br J Clin Pharmacol 2006;63:136-47
  2. Howard RL, Avery AJ, Howard PD, Partridge M. Investigations into the reasons for preventable drug related admissions to a medical admissions unit: observational study. Qual Saf Health Care 2003;12:280-5
  3. More on NSAID adverse effects. Bandolier 2000;7:6-8
  4. Belsey J. The cost impact of NSAID-induced gastrointestinal adverse events. Managing Pain in Practice 2010;1:3-11
Acknowledgements

Thanks to all the pharmacists and others who are contributing to this work. Training sessions and some data collection are supported by an educational grant from Pfizer Ltd.

About the author

Carina Livingstone is associate director of medicines use and safety, East & South East England specialist pharmacy services. Those interested in collecting evidence about targeted MURs can email [email protected] or [email protected]

Citation: The Salvadore URI: 11090832

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