NSAIDS Prescribing Audit

1. NSAIDS Prescribing Audit By Dr Sadaf Cheema GPST3

2. Overview: There are risk of gastrointestinal and renal safety concerns with NSAIDS but recently noticed increased risk of cardiovascular events with Diclofenac and COX-2 inhibitors. Therefore reduce prescribing of NSAIDS is part of medicine management action plan.

3. Audit: • Caritas Group is looking into the improvement of prescribing appropriate NSAIDS i.e. Ibuprofen or Naproxen instead of diclofenac or COX-2 inhibitors. • Caritas Group has a lower indicator value for prescribing Ibuprofen and Naproxen compare to other NSAIDS in relation to its cluster practices and this audit will show us if Caritas Group is prescribing inappropriate NSAIDS i.e. Diclofenac or COX-2 inhibitors.

4. Question: • Is our NSAIDS prescribing rate inappropriate?

5. Method: • Review NSAIDS prescribing esp. Diclofenac over the year 2013 and reviewed repeat prescriptions. • BNF to get names of all UK licensed NSAIDS. • Produce report of all patients on these NSAIDS.

6. Total Number of Patients Found on Diclofenac: • 48 43 • Out of 48 patients 5 patients are on repeat prescription but never issued in year 2013 and 2 out of those are with CVS risk. • What is high Risk: Those with CVD >20% based on QRISK score.

7. Conditions Being Treated: • Osteoarthritis, • Rheumatoid Arthritis, • Inflammatory Arthritis, • chronic shoulder pain, • chronic lower back pain with/without sciatica, • Arthralgia of multiple joints, • Neck and back pain, • Low back pain, • Long standing bilateral anterior/lateral groin and thigh pain, • Osteoarthritis in feet, • Tennis elbow

8. CVD Risk • 9 patients on diclofenac known with CVD risk >20% = (20.93%) • 10 patients who are known to have HTN, DM, IHD and/or Obesity but CVD risk not known as was not calculated on the system = (23.25%) • 24 patients who do not have CVD Risk >20% = (55.81%)

9. Reason why not naproxen/ibuprofen whose CVD Risk >20% or unknown Risk: • 12 patients: Doesn't seem to have been offered alternative medication • 2 patients: Suffered with side effects-stomach upset, diarrhoea and sickness • 4 Patients: trial of naproxen given but did not find effective • Other reasons: • Has tried ibuprofen in 2004 but not effective enough for chronic shoulder pain. However maybe worth reviewing as that's so long ago. • Patient reluctant to take any alternative treatment and is pleased with the relief that Diclofenac brings him despite of the increased CVD risk it may give him. • Was initially on naproxen however was taken off due to risks of taking NSAIDS long term. However didn't find paracetamol or codeine good enough for pain relief so was started on diclofenac instead. Not known why he didn't go back on naproxen instead.

10. Lessons: “Remove diclofenac from lists of essential drugs” Diclofenaccarries an unacceptably high risk of cardiovascular side effects and should be removed from national lists of essential drugs, say researchers. It is also very popular. Diclofenac alone accounted for almost 28% of the market for non-steroidal.

11. Recommendations for Practice: • Regular reviewing of all NSAIDS prescribing. • Stop all repeat and ask patients to come in for medication review. • QOF vs Good Practice – NSAIDS not likely to become part of QOF but good practice to check U&Es annually and review use. • If using Diclofenac for OA, check have they used topical NSAIDS first. • Re Audit in 3 months time. • Argument for community pharmacy ?CCG funding.

12. Re-audit: • Re-audit in 3 months time to see changes in practice.

13. References: • BMJ Research article; http://www.bmj.com/content/346/bmj.f1053 • Local CCG guidelines.

14. Questions

15. Thanks For Listening