Medication Review

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    Medication review: improving patient
    safety and addressing medicines

    Dr Duncan Petty
    Research Pharmacist
    Practice Pharmacist Bradford/Airedale PCT
Clinical Medication Review

   Clinical medication review is the process where a
   health professional reviews the patient, the illness,
   and the drug treatment during a consultation.
   It involves evaluating the therapeutic efficacy of each
   drug and the progress of the conditions being treated.
   Other issues, such as compliance, actual and potential
   adverse effects, interactions, and the patient’s
   understanding of the condition and its treatment are
   considered when appropriate.

 Zermansky, Petty, Raynor et al. BMJ 2001;323:1340-3
Aims of Clinical Medication Review

•optimising the impact of medicines
•minimising the number of medication-related problems
•reaching an agreement with the patient about treatment
•reducing waste
Aims of Clinical Medication Review

What do we mean by medicines safety?
Causes of medicine risk

• Iatrogenic
• Lack of monitoring
• Wrong choice of drug or dose
• Drug interactions
• Drug disease interactions
• Poor adherence
• Administration errors

• Under-treated and untreated conditions
Lack of monitoring

   What are most common drugs causing admissions were
   monitoring may have avoided the admission?
    • Diuretics
    • Warfarin
    • Hypotensives

Pirmohamed et al BMJ 2004;329:15-19
Howard RL et al. Br J Clin Pharmacology 2006
Medicines associated with drug
related admissions and higher risk

Diuretics (in older people)
Hypotensives (in older people)
Hypnotics (in older people)
Antipsychotics (in older people)
Tricyclic antidepressants (in older people)
Hypoglycaemics (especially long-acting sulphonylureas)
Medicines with a narrow therapeutic index e.g. antiepileptics, lithium, theophylline
Reasons for medicine related admissions

Prescribing (35%) e.g.
    •   NSAIDs with 2 or more risk factors for GI bleed
    •   Antiplatelets with 2 more risk factors for GI bleed
Monitoring (26%) e.g.
    •   Diuretics – not monitoring fluid balance, renal function.
    •   Sulphonyrueas – failure to monitor blood glucose
    •   Digoxin – failure to monitor dig levels/renal function
Adherence (30%) e.g.
    • Loop diuretics – CCF exacerbation
    • Antiepileptics – fitting
    • Inhaled steroids – asthma exacerbation
Monitoring and review

  Monitoring and Reviewing
                            Monitor                            Re vie w
  Who?                      Care r                             Clin ical Pro fessional
  What?                     One condition or para meter        Holistic:
                                                                            Patient
                                                                            Illness
                                                                            Disease
                                                                            Treat ment
  How?                      Measurement                        Judgement
  When?                     By protocol                        By protocol or reactive
  Conte xt                  Strict c riteria                   Gu idelines
                            Protocol                           Ev idence
                                                               Professional assessment
  Action if satisfactor y   Continue treatment until revie w   Continue or cease treatment
  Action if adverse         Modify treatment only with in      Stop or change treatment
                            protocol                           Further monitoring
                            Further monitoring within          Reconsider diagnosis
                            Refe rence to prescriber
  Ti metable                Strict ly by protocol              Professional judgement,
                                                               including opportunism, but may
                                                               be guideline or agreed policy.
Evidence based medicines not prescribed

  A clinical medication review involves looking for indications that
  are not treated or are undertreated. e.g.

• bisphosphonates for secondary prevention of osteoporosis
• aspirin and statins in cardiovascular disease
• aspirin or warfarin in atrial fibrillation

• analgesics for osteoarthritis
CMR and falls

Reviewing sedatives and hypnotics
Reviewing hypotensives
Reducing total number of medicines
Calcium and vitamin d 800iu daily
Clinical medication review by a pharmacist of elderly people
living in care homes - randomised controlled trial

Outcomes during six months follow-up period
                      Intervention   Control        Difference

                                                    (RR 95%CI P value)
GP consultations      2.9 (1 to 4)   2.8 (1 to 4)   1.03 (0.93 to 1.15)
   †Number (IQR)                                    0.50

Falls †Mean (IQR)     0.8 (0 to 1)   1.3 (0 to1)    0.59 (0.49 to 0.70)

Zermansky AG, Alldred DP, Petty DR et al.
Age and Ageing 2006 35: 586-591
Unplanned hospital admissions
Emergency admissions by ACS condition 2003/04
   ACS condition                                     No. of spells
   • COPD                                            106,517
   • Angina (uncomplicated)                          79,228
   • ENT infections                                  72,831
   • Convulsions and epilepsy                        64,664
   • Congestive heart failure                        62,582
   • Asthma                                          61,264

   Delivering quality and value. Institute for Innovation and Improvement.
Why are medicines wasted?

Jesson et al described 7 reasons for unused medicines

1. Too much stock at home
2. Medicines passed expiry date
3. Error of prescription, order or supply

4. Death
5. Medication no longer required as changed by prescriber
6. Medication stopped by patient
7. Adverse effects’ classed as unavoidable.
Disadvantages of repeat

   • excessive quantities prescribed
   • different durations for difference drugs
   • discontinued medicines not deleted from repeat prescription.
   • drugs prescribed regularly rather than PRN
   • prescribing of expensive dosage regimens e.g. lisinopril 10mg bd
     rather than 20mg od
Reduction in numbers of medicines
in RCTs of pharmacist reviews

• Pharmacist review in general practice and care homes generally
  show a reduction in total number of repeat medicines.1,2,3

• No published evidence for benefits of general practitioner review.

1.Furniss L, Craig S, Scobie et al. Br J Psychiatry 2000;176:563-7
2.Lenaghan E, Holland R, Brooks A. Age Ageing 2007;36:292-7
3. Roberts M, Stokes J, King M et al. Br J Clin Pharmacol 2001;51:257-65
Example of changes to repeat medicines as to their
Numbers (%) of patients experiencing at least one change
a result of clinical medication review
repeat prescriptions during the study period

   Numbers (%) of patients experiencing at least one change to their
   repeat prescriptions during the study period

    Change               Intervention    Control       Total
                           (n=581)       (n=550)     (n=1131)
    Start new drug         265 (46%)    270 (49%)    535 (47%)
    Stop existing drug     239 (41%)    180 (33%)    419 (37%)
    Switch drug            119 (20%)      93 (17%)   212 (19%)
    Dose change             98 (17%)      61 (11%)   159 (14%)
    Generic change          64 (11%)      37 ( 7%)   101 ( 9%)
    Formulation change      17 ( 3%)      12 ( 2%)    29 ( 3%)
    Frequency change          6 ( 1%)      0 ( 0%)     6 ( 1%)
Cost savings identified in RCTs
of pharmacist reviews

Zermansky et al (2001)               £61/patient/year

Rodgers et al. (1999)                £63/patient/year

Mackie et al (1999) for every £1 spent on pharmacists
                    £2 per year was saved on medicine costs.

1. Zermansky AG, Petty DR, Raynor DK et al. BMJ 2001:323; 1340-1343.
2. Rodgers et al. Brit J Gen Pract 1999; 49: 717-720
3. Mackie CA et al. Pharm J 1999; 263:R7

• One of the main objectives of CMR is to reduce clinical risk by
 ensuring appropriate use of repeat medicines

• Reducing waste is an additional benefit

• Most medication reviews are done by GPs

• Most research evidence stems from pharmacist reviews

• Competency and access to necessary “enablers” are pre-requirements
 for CMR and are more important than which professional group does
 the review.

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