prescribing - Centre for Medicines Optimisation

Actions for Commissioning Teams
Avoiding Admissions to Hospital
due to Problems with Medicines
Information for Care Homes
March 2012
This presentation updates a previous publication
“APT 14 – Admissions Avoidance”
from September 2009
Actions for Commissioning Teams
What are we covering?
o What are the issues?
o Adverse drug reactions
• Causes
• Who’s at risk?
o Specific medicines causing ADRs
Antidiabetic drugs
o The role of the prescriber
o The role of the care home
o A note about falls
Actions for Commissioning Teams
Why are we looking at this?
In 2010/2011 there were 2,043,532 admissions to hospitals in
the West Midlands.
Data: HES
Some hospital admissions could be avoided including some of
those related to adverse drug reactions (ADRs).
o For example patients who experience stomach bleeds due to the
use of Non-Steroidal Anti-inflammatory Drugs (NSAIDs) such as
ibuprofen or aspirin.
ADRs affect patient’s health and wellbeing and are associated
with significant costs (costs of care and costs of potential
Actions for Commissioning Teams
Adverse Drug Reactions
Some common adverse drug reactions that may increase a
patient’s risk of being admitted to hospital are1:
o stomach problems such as bleeding, constipation and
o heart complications and symptoms such as:
• shortness of breath or trouble breathing
• new or worsening chest pain
• new or worse pain in legs when walking
o breathing problems (respiratory symptoms)
o poor control of blood sugars (glycaemic control)
Actions for Commissioning Teams
ADRs: which drugs are most
commonly associated with
preventable hospital admissions?
Drugs that can cause preventable hospital admissions2,3:
o Non-steroidal anti-inflammatory drugs (NSAIDs) e.g. diclofenac
o Antiplatelets (which may be used for thinning the blood) e.g. low
dose aspirin and anticoagulants (to prevent blood clotting) e.g.
o Diuretics (water tablets) e.g. furosemide
o Angiotensin converting enzyme inhibitors/angiotensin receptor II
blockers (to reduce blood pressure) e.g. ramipril or losartan
o Antidiabetic drugs e.g. insulin
o Drugs affecting the central nervous system (CNS) e.g.
antiepileptics, opioid analgesics and antidepressants
o Digoxin – for irregular heart rhythm/beats
The following four drug classes account for >50% of
preventable drug related admissions2:
o NSAIDs, antiplatelets, anticoagulants, diuretics.
Actions for Commissioning Teams
Causes of preventable
Incorrect selection of drug, dose, frequency or route
“High risk” prescribing (e.g. use of drugs when there are
Inadequate medication monitoring
Inadequate medication review
Badly designed repeat prescribing systems
Carer and patient not understanding how to take the medicine
regularly and correctly
Poor communication across organisations e.g. community (GP
and wider healthcare teams, pharmacy and care home),
hospitals and social care
Actions for Commissioning Teams
ADRs: which patients are most at
Risk of an ADR resulting in hospital admission is particularly
high in the following groups of people1,4:
o Elderly people
o Patients with multiple diseases and conditions (co-morbidities)
o Patients taking several drugs
o Patients with acute medical problems
o Patients with impaired memory or understanding (cognition –
sometimes these are patients with dementia or learning
o Patients who may be in a muddle with their prescribed medicines
(with poor adherence)
o Patients with impaired kidney (renal) function
Actions for Commissioning Teams
Avoiding ADRs:
If an NSAID is needed prescribers will:
• try to use the NSAID with the safest track record, at the lowest
effective dose for the shortest period of time e.g. ibuprofen or
try not to prescribe an NSAID with drugs such as:
o citalopram/fluoxetine (antidepressants from the class of drugs
known as selective serotonin re-uptake inhibitors – SSRIs)
o anticoagulants
o antiplatelet drugs
o corticosteroids (e.g. prednisolone) as they can increase the
chance of stomach bleeds
o If NSAIDs are prescribed with the above drugs they may also use
a proton pump inhibitor (PPI) such as omeprazole to protect the
monitor kidney function if they are obliged to use an NSAID at
the same time as certain classes of antihypertensive drugs as
there is an increased risk of kidney damage or failure.
Actions for Commissioning Teams
Avoiding ADRs:
If prescribing a diuretic prescribers will:
carefully consider the need for a diuretic as they are often
overused in the elderly.
try not to prescribe for certain conditions for example ankle
swelling not associated with other conditions.
o Ankle swelling will usually respond to increased movement
(getting up and walking about where possible), raising the legs or
even support stockings.
regularly review the use of diuretics for the treatment of
hypertension or heart failure.
o They will assess the patient’s hydration status, kidney function
and blood electrolytes.
Actions for Commissioning Teams
Avoiding ADRs: antiplatelets such as aspirin
and clopidogrel7
Prescribers will carefully weigh up the risks and benefits of the
use of an antiplatelet drug as it can increase the risk of
bleeding complications, particularly stomach bleeds.
If aspirin is needed the prescriber will:
o use 75 mg daily unless a higher dose is indicated.
o For patients at high-risk of stomach complications, a PPI (such as
omeprazole) can be added.
If clopidogrel is needed the prescriber will:
o check if the patient is at high risk of GI bleeding then consider a
drug to protect the stomach.
o consider PPIs other than omeprazole or esomeprazole*.
*Omeprazole or esomeprazole may reduce antiplatelet action of clopidogrel8
Actions for Commissioning Teams
Avoiding ADRs:
In order to prevent ADRs related to the use of warfarin
prescribers will:
• Check:
o is INR (blood clotting test) being monitored regularly?
o is the INR level okay?
Watch out for interacting drugs
o and exercise care when starting, stopping or altering the dose of an
interacting drug.
Check if there are any disease states or lifestyle changes that
will affect INR?
o Carers should notify the GP if the patient has changed their eating habits
i.e. lack of appetite resulting in less food consumed – because this can
affect the patients INR.
Provide additional information so that care homes can ensure
they have written safe practice procedures for administration of
Risk assess monitored dosage systems
o Dose changes more difficult using these systems
o Use of anticoagulants in these dosage systems not recommended
Actions for Commissioning Teams
A note about patients with diabetes
for care homes
• Diabetes is a chronic and progressive illness. If
untreated or not managed well, patients with
diabetes may develop serious complications.
• People with diabetes are twice as likely to require a
hospital admission compared with the general
population. At any one time, at least one in 10 people
in hospital has diabetes.10
Actions for Commissioning Teams
Avoiding ADRs: antidiabetic drugs
Prescribers will exercise care when prescribing insulin and
some oral antidiabetic drugs (such as gliclazide and
repaglinide) because:
o they may cause low blood sugar levels (hypoglycaemia) which
could lead to a patient needing to go to hospital.
Factors that increase the risk of hypoglycaemia include11:
inappropriately high doses of insulin or some antidiabetic drugs.
forgotten or delayed meals, or insufficient carbohydrate intake.
excessive alcohol intake (or drinking alcohol without food).
more physical activity than usual.
Actions for Commissioning Teams
Avoiding ADRs: antidiabetic drugs
Prescribers, pharmacists and care homes should discuss and
reinforce information on hypoglycaemia.
Carers should ensure that they11:
o are aware of situations that increase the risk of hypoglycaemia.
o encourage residents to eat regularly and include a portion of
starchy carbohydrate with each meal.
o are able to recognise early symptoms and how to treat promptly.
o check correct insulin has been dispensed.
o always have treatment and information for hypoglycaemia readily
available for residents and other carers (e.g. if going out to daycentres, hospital appointments, trips out).
o encourage patients to have identification to alert others (e.g.
identity bracelet or card).
Actions for Commissioning Teams
Avoiding ADRs: antidiabetic drugs
More information on insulin….
Insulin treatment is an important cause of hospital admissions,
mainly as a consequence of severe hypoglycaemia.
o Insulin errors (wrong insulin product, wrong insulin dose, omitted
or delayed insulin dose) account for 60% of insulin-related
adverse events reported in the UK.12
o One report shows that for the period 1 November 2003 to 1
November 2009, there were 16,600 incidents relating to insulin
including six deaths and 12 resulting in severe harm.12
o Some organisations have access to specialist diabetic services in the
community for further support
Actions for Commissioning Teams
Avoiding ADRs: antidiabetic
National guidance and recommendations for the safer use of insulin
o Insulin doses must be measured and administered using an
insulin syringe or commercial insulin pen device
o Intravenous syringes must never be used for measuring or
administering insulin.
o The term ‘units’ should always be used. Never use abbreviations
such as ‘U’ or ‘IU’
o Adult patients on insulin should receive a patient information
booklet and Insulin Passport
o When prescriptions of insulin are prescribed, dispensed or
administered always check that you have the correct insulin
Actions for Commissioning Teams
The role of the
Before prescribing a drug the prescriber will carefully assess
potential harms and benefits and consider whether the
medicines is appropriate for the patient.
Prescribers should:
o consider co-morbidities or allergies, adverse effects to the drug
and interactions with other medicines
o check if the patient is taking any Over The Counter (OTC)
preparations that could interact with the prescribed agent?
o consider any non-drug interventions or options
Where possible they will:
o involve patients and carers in prescribing decisions and inform
them of potential adverse effects
o explain clearly directions for use of medicines.
They will also:
o use appropriate formulations e.g. if the patient has difficulty
swallowing, consider liquid /dispersible formulations
Actions for Commissioning Teams
Safe prescribing – the prescribers
The prescriber will aim to:
Review medication regularly
o Medicines which appear to have no benefit or have unacceptable
side effects should be discontinued – the care home should keep
the prescriber informed of how their residents respond to
medicines, especially if an ADR is suspected.
Undertake blood tests to ensure the body is operating
appropriately and/or the drug is working properly
o Liver function tests (LFT) to check the health of the liver.
o Urea and electrolytes (U&E) to check the kidneys are working.
o Blood tests to check if the drug is working properly (e.g. INR for
Ensure effective communication across organisations e.g.
community (GP and wider healthcare teams, pharmacy and
care home), hospitals and social care
o Review process for actioning medication changes.
Actions for Commissioning Teams
Tips for safe medicines management
systems in care homes
The role of the care home:
Check medication and ensure you have information needed to
safely administer medication. Ask for further information if you
need it.
Share and communicate necessary information.
o Check medication records match at the surgery, home and
pharmacy. Inform pharmacist of any changes to medication as
soon as possible.
o Ensure all monitoring is up to date
• find out if monitoring is needed for a particular medication e.g. INR for
o Ensure you have defined the allergy
• sometimes what has been recorded as an allergy was a reaction or
expected side effect to a medication e.g. diarrhoea when taking
Actions for Commissioning Teams
Tips for safe medicines management
systems in care homes
Make sure residents take their medicines at the correct time
(this doesn’t apply to all medicines but it will with some).
Residents taking quetiapine, risperidone or other
antipsychotics should be reviewed regularly.
If a resident is taking a diuretic and is dehydrated from not
drinking, check with the GP whether the diuretic should still be
If the resident is taking diabetic medicines and not eating,
check with the GP if diabetic medication should be given.
If a resident is prescribed citalopram and another drug such as
aspirin or alendronate, they may also be prescribed
omeprazole to protect their stomach. (If not, you may want to
check this out with the GP).
Find out where on the body and how often emollients should
be applied.
Actions for Commissioning Teams
A note about falls for Care Homes
Falls are a major cause of disability and mortality in older
Studies found that in people older than 60 years, falls may be
associated with the use of some medications including:14
benzodiazepines e.g. diazepam
other sedatives and hypnotics e.g. temazepam
antidepressants e.g. fluoxetine/citalopram
antipsychotics e.g. quetiapine
NSAIDs e.g. diclofenac
antihypertensives e.g. ramipril
Actions for Commissioning Teams
A note about falls for Care Homes
NICE recommend that older people should be asked routinely
whether they have fallen in the last year.15
Patients reporting a fall or considered at risk of falling should
be considered for an individual multifactorial intervention
strength and balance training
home hazard assessment and intervention
vision assessment and referral
medication review with modification or withdrawal
Actions for Commissioning Teams
1) Leendertse AJ, Egberts AC, Stoker LJ et al. Frequency of and risk factors for preventable medicationrelated hospital admissions in the Netherlands. Arch Intern Med 2008;168:1890-6.
2) Howard RL, Avery AJ, Slavenburg S et al. Which drugs cause preventable admissions to hospital? A
systematic review. Br J Clin Pharmacol 2007;63:136-47.
3) Purmohamed, M, James S, Meakin S et al. Adverse drug reactions as cause of admission to hospital:
prospective analysis of 18.820 patients. BMJ. 2004; 329: 15-19
4) Avery AJ. Top tips for GPs. Strategies for safer prescribing. National Prescribing Centre. 2011. <accessed 2/2012>
5) Non-steroidal anti-inflammatory drugs. Chapter 10. Section 10.1.1. British National Formulary 2011. 62nd
edn. London: British Medical Association and Royal Pharmaceutical Society of Great Britain.
6) Diuretics Chapter 2. Section 2.2 British National Formulary 2011. 62nd edn. London: British Medical
Association and Royal Pharmaceutical Society of Great Britain.
7) Antiplatelet drugs Chapter 2. Section 2.9 British National Formulary 2011. 62nd edn. London: British Medical
Association and Royal Pharmaceutical Society of Great Britain.
8) Clopidogrel and proton pump inhibitors: interaction-updated advice. Drug Safety Update. Volume 3. Issue
9, April 2010
9) Medicines and Healthcare products Regulatory Agency. 2010. <accessed 2/2012>
9) National Patient Safety Agency. Actions that can make anticoagulant therapy safer. Patient Safety Alert. No.
18. 2007
10) Diabetes in the UK 2010: Key statistics in diabetes. Diabetes UK
11) Recognition, treatment and prevention of hypoglycaemia in the community. NHS diabetes. 2012.
ypoglycaemia_in_the_community/ <accessed 2/2012>
12) The adult patient's passport to safer use of insulin. Patient Safety Alert. National Patient Safety Agency.
2011. <accessed 2/2012>
Actions for Commissioning Teams
13) New insulin safety guidance issued to reduce wrong dosages. National Patient Safety Agency (NPSA).
2010. <accessed 2/2012>
14) Woolcott JC, Richardson KJ, Wiens MO et al. Meta-analysis of the Impact of 9 Medication Classes on
Falls in Elderly Persons. Arch Intern Med 2009;169:1952-60
15) Falls:the assessment and prevention of falls in older people. CG21. National Institute for Health and
Clinical Excellence. 2004. <accessed 2/2012>

similar documents