Clopidogrel Audit

1. Clopidogrel Audit Vikas Jasoria December 2006

2. What is it? • Clopidogrel is a thienopyridine antiplatelet drug which reduces platelet aggregation by inhibiting the binding of adenosine phosphate to its platelet receptor • IN SIMPLE TERMS • Anti-platelet which works in a different way to aspirin

3. Why Clopidogrel? • Increasing prescriptions • 2003: • 2.1m prescriptions costing £87m • Increase of > 50% since 2002 • Length of course often not specified • Patients on Clopidogrel indefinitely when may not need to be the case

4. Why Clopidogrel? • Prescribers incentive scheme 2006/2007

5. In real terms….. • 28 tablets cost £ 35.31 • £ 423.72 per patient per year (aspirin £ 10.44) • £ 413.28 per year saving per patient!!!!!! • Stop giving BIG PHARMA money……. • Use money for other health services……

6. The Evidence • Primary Prevention • CHARISMA trial • Clopidogrel plus aspirin is no more effective than aspirin alone in preventing major cardiovascular events

7. The Evidence • Antithrombotic Trialists Collaboration (BMJ2002;324:71) • Clopidogrel is an effective alternative if cannot take aspirin

8. The Evidence • Post MI/ACS: • CLARITY trial (NEJM2005:352;1179) & COMMIT study (Lancet2005:366;1667) • Addition of clopidogrel to aspirin improves outcomes (Decreased mortality and CV complications) • No additional risk of bleeding when used in combination • Clopidogrel and aspirin should be used in standard treatment post MI, at least in short term

9. The Evidence • NICE (NSTEMI): • Continue up to 12 months after most recent acute episode ACS • Prescribers incentive scheme: • Clopidogrel licenced for use in MI (STEMI) up to 35 days after the event •  For cardiac event: • No patient should be on clopidogrel for secondary prevention for > 1 year

10. The Evidence • JBS-2 2005 Guideline: • IF ASPIRIN NOT TOLERATED: • Prescribe clopidogrel 75mg od for • Vascular disease • Diabetes • Asymptomatic whose 10 year risk > 20%

11. Indications – NO CVD & Aspirin intolerant • Over 50 and > 20% Framingham 10 yr risk • Diabetics • Age 50 years or over • Diabetes > 10 years • Taking treatment for hypertension • Evidence of target organ damage • All people with target organ damage from hypertension • AF

12. Indications – CVD & Aspirin intolerant • CVD? • With aspirin: • Myocardial infarction, angina • If aspirin intolerant: • Non-haemorrhagic cerebrovascular disease (not in AF) • Peripheral vascular disease • Atherosclerotic renovascular disease

13. Criteria & Standards • Patients on clopidogrel should have a valid clinical indication recorded • Standard: 90% • Patients prescribed clopidogrel as monotherapy should have documented contra-indication or intolerance of aspirin: • Standard: 90% • Patients on clopidogrel for ACS or MI are on clopidogrel for < 12 months after most recent acute cardiac episode • Standard: 90%

14. Method • Patients prescribed clopidogrel over last 90 days from 8th November 2006 • Computer & paper notes (where indicated) • Correspondence letters • Excel Spreadsheet  TIME CONSUMING !!!!!

15. RESULTS

18. Standard Met NO (NEARLY!!!)

19. Discussion • Clinical indications? • “post hypotensive episode/migraine” • Registered newly and was on clopidogrel before – no documentation as to why • ? Post valve replacement and warfarin intolerant • Also on aspirin • January 2003: “Very keen to try clopidogrel for 1 month, has read about it in the paper”; “No more chest pain since starting clopidogrel” • No intolerance of aspirin noted

20. Discussion • ?Swapping to clopidogrel because of need for NSAID and aspirin • Started aspirin and clopidogrel 2002 after more TIAs. • Advised by neuro then to cut out aspirin slowly and continue clopidogrel • No intolerance of aspirin noted • Evidence changes with time… we need to keep up

21. FIX IT! • Documentation, documentation, documentation • Computer popup needed everytime Clopidogrel prescribed • “Is there a valid clinical indication documented in the notes” • Consider cost/benefit of patient requests for Clopidogrel when not indicated • Is it worth it? • Need to get a better history from new patients • Stop prescribing repeats and ask patients to come in for medication review if needed • Contacting individual GPs with their patients that need to be addressed

23. Standard Met NO

24. Discussion • CVA/TIA who are on both aspirin and clopidogrel • Old vs. new evidence • If aspirin is stopped then reason in notes needs to be more clearly documented • Patient awaiting angio after trop negative CP ?likely diagnosis stable angina but not aspirin intolerant

25. FIX IT! • Contact individual GPs • If no intolerance of aspirin then stop Clopidogrel and change to aspirin • ? Write to patients ?

27. Standard Met NO (NEARLY!!!)

28. NOTE!!!! • Excluded in results those that had cardiac event and stenting • Controversial as to length of treatment of clopidogrel post stent • Numbers are low!

29. Discussion • Patient had NSTEMI November 2005 on discharge summary says "review in clinc" but no evidence of formal review note

30. FIX IT! • Contact GP involved • Consider stopping clopidogrel as > 1 year post MI • Set computer reminder to prompt if > 1 year post most recent cardiac event

31. CONCLUSIONS

32. Conclusions • Old evidence vs. New evidence • MEDICATION REVIEWS IMPORTANT • Documentation, documentation…….. • Not far from standards in 2/3 • Need to address Clopidogrel monotherapy group • Solutions involve contacting individuals and making changes • Difficult audit – which one for submission if any? • Re-audit in April 2007

33. Thank You