RADs MUR guide
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RADs MUR guide Document Transcript

  • 1. Guide to carrying out a Medicines Use Review(MUR) with a patient taking an ACE Inhibitor or anAngiotensin II Receptor AntagonistBackgroundNational guidelines recommend ACE inhibitors (ACEIs) as the renin-angiotensin drugs of first choice.Angiotensin II Receptor Antagonists (A2RAs) should be reserved for patients unable to tolerate ACEIs due toside-effects such as ACEI-induced cough.Many Primary Care Trusts and GP practices are prioritising this area of prescribing for review.Community pharmacists can make an important contribution to this by focussing medicines use reviews(MUR) on patients taking ACEIs and A2RAs.This guide has been produced as a resource to community pharmacists carrying out medicines use reviews.The guide focuses on the use of ACEIs and A2RAs. It is recognised that patients taking ACEIs or A2RAs,whether for heart failure, hypertension or other indications, may also be taking other medication and mayhave co-morbidities. This needs to be taken into consideration during the medicines use review.Further support material on ACEI / A2RA prescribing is available at www.npci.org.ukGeneral PrinciplesData indicate that by reviewing current prescribing of renin-angiotension medicines the NHS can makesignificant savings without adversely affecting patient care.There are four main potential therapeutic changes in this area:- - from an A2RA to an ACEI - from the combination of an A2RA plus an ACEI to an ACEI alone - from one ACEI to another ACEI - from one A2RA to another A2RA.These medicines are mainly prescribed for five conditions:- - diabetes - hypertension - post-myocardial infarction - heart failure - chronic kidney disease.Before considering a change in medicine(s) in this class, clinicians and prescribing managers should befamiliar with the evidence-based therapeutics for each of these medicines singly and in combination in all thetarget conditions for which they are being used. They should then consider the application of that evidence toeach individual patient. Whilst there are dosage comparison charts available and most patients can be safelyand successfully transferred from one medicine to another, careful monitoring is advised when undertakingmedication changes in this class of medicines for these target conditions. There will be some patients,particularly those with unstable and /or multiple conditions, where changing medication will be inappropriate.Before changing most patients’ renin-angiotensin medicines, a prior discussion with each patient and aninformed decision about each medication change and the monitoring required to accompany each changewould be prudent. This discussion should be documented in the patient’s notes.These changes should maintain or improve quality whilst reducing costs.However, whilst reviewing patients taking renin-angiotension medicines there is also the opportunity toreview whether some patients need to change from an ACEI to an A2RA – usually because the ACEI is nottolerated. In addition, there is some evidence that using an A2RA in combination with an ACEI may be NPC materials may be downloaded / copied freely by people employed by the NHS in England for purposes that support NHS activities in England. Anyperson not employed by the NHS, or who is working for the NHS outside England, who wishes to download / copy NPC materials for purposes other than their personal use should seek permission first from the NPC. Email: copyright@npc.nhs.uk Copyright 2008
  • 2. required in a small number of patients with heart failure, and these patients may require a change from ACEIto an ACEI plus A2RA. These changes would improve quality of care and increase costs.Before the Medicines Use ReviewChange cannot be implemented without involving the prescriber. This is best done at the outset. Beforecarrying out the medicines use review, it would be helpful to discuss and agree your plans with your localpractices. They may already be reviewing or preparing to review this area of their prescribing and would findyour input valuable.Complete as much information as possible prior to the MUR on the MUR form e.g. pharmacy details andpatient and prescription details available from the patient’s medication records (PMR). This will save timeduring the review, allowing you more time to discuss medication issues with the patient.Selecting patients 1. Using your PMR identify patients on repeat ACEIs or A2RAS and ask them if they would like to come in for a medicines use review at a convenient time. 2. When a patient brings a prescription in for an ACEI or A2RA ask them if they would like to come in for a medicines use review at a convenient (or there and then if time permits).Indications: ACEIs and A2RAsThe table below provides a quick guide to the licensed indications of some commonly prescribed ACEIs andA2RAs. For full details of product licenses see BNF and Summary of Product Characteristics (SPC). Hypertension Heart Failure Diabetic MI Secondary Nephropathy Prevention Angiotensin converting enzyme inhibitors Captopril √ √ √ √ Cilazapril √ √ Enalapril √ √ Fosinopril √ √ Imidapril √ Lisinopril √ √ √ *√ Moexipril √ Perindopril √ √ √ Quinapril √ √ Ramipril √ √ √ Trandolapril √ √ Angiotensin II receptor antagonists Candesartan √ √ Eprosartan √ Irbesartan √ √ Losartan √ √ Olmesartan √ Telmisartan √ Valsartan √ √ √ = licensed indication * = short-term use only NPC materials may be downloaded / copied freely by people employed by the NHS in England for purposes that support NHS activities in England. Anyperson not employed by the NHS, or who is working for the NHS outside England, who wishes to download / copy NPC materials for purposes other than their personal use should seek permission first from the NPC. Email: copyright@npc.nhs.uk Copyright 2008
  • 3. Suggested questions to ask during the reviewPrescribed and over-the-counter (OTC) medicineAsk the patient what medication they are currently taking for high blood pressure / heart conditions.Ask the patient to give details of any prescribed and over-the-counter medicines. • Compare this with the patient’s PMR record • Record the patient’s medication on the MUR form, including any OTC and complimentary therapies. o Is the patient taking any other medication, prescribed or over-the-counter for other conditions? o Are there any potentially clinically significant interactions? o If the patient is taking an A2RA, have they previously tried an ACEI? Is there a record of the patient having previously tried an ACEI? If there is no record of the patient having previously tried an ACEI make a note of this to inform the prescriber.Dosage regimenAsk the patient when they take their medication (prescribed and OTC) and how much they take. • Discuss possible contraindications e.g. concomitant NSAID use with ACEI • Is the dose appropriate – is there a record of dose titration? • If newly prescribed ACEI / A2RA, is the patient aware of possible first dose hypotension, particularly if taking diuretics.Patient’s knowledge of their medicinesAsk the patient if they understand what their medication is for. Do they know how it works? • If the patient is unsure of what their medicines do, discuss how they work and how they can help to control symptoms.ComplianceAsk the patient if they ever forget to or decide not to take their medication. • Discuss their reasons for not taking their medicines. Discuss how the medication can help and the importance of taking it even though there may be no apparent symptoms e.g. for hypertension. • Discuss the patient’s feelings about taking their medication and advise on lifestyle changes.Lifestyle interventions • Ask about diet and exercise patterns and offer guidance and if possible written information • Ask about alcohol consumption and encourage patients to cut down if they drink excessively • Encourage patients to take regular exercise such as brisk walking • Encourage patients to reduce their salt intake • Discourage excessive consumption of coffee and other caffeine-rich products • Offer smokers advice and help to stop smoking – does the pharmacy provide a stop-smoking service? • Are there any local initiatives to provide support and promote lifestyle change – e.g. local patient support groups NPC materials may be downloaded / copied freely by people employed by the NHS in England for purposes that support NHS activities in England. Anyperson not employed by the NHS, or who is working for the NHS outside England, who wishes to download / copy NPC materials for purposes other than their personal use should seek permission first from the NPC. Email: copyright@npc.nhs.uk Copyright 2008
  • 4. Are side-effects present?Ask the patient if they think they are experiencing any side-effects from their medication.CoughCough is a well recognised side-effect of ACEIs and and may lead to withdrawal or change of treatment insome patients. However, there are many other conditions which can be the cause of a persistent cough,including heart failure - which may be the indication for the ACEI. Ascribing the cause of a persistent coughto the ACEI in someone taking an ACEI may not always be correct.ACEI-related cough can occur up to several months after initiation of therapy. It is not clear whether it is doserelated.ACEI-induced cough stops a few days to weeks after stopping ACEI therapy.If the patient is taking an ACEI and has a dry persistent cough that interferes with sleep, and other causeshave been ruled out, the patient should be referred to their GP. • Offer appropriate advice on side-effects • Discuss the safety and effectiveness of their medicines.General issues • What is the local PCT / practice formulary choice of ACEI or A2RA? • Is the PCT / local practice prioritising ACEI and A2RA prescribing for review? • Has the patient had a full medication review within the last 12 months? • Are blood tests up to date? • When was the last time blood pressure was monitored? • Are there any symptoms present which require urgent referral to the GP? NPC materials may be downloaded / copied freely by people employed by the NHS in England for purposes that support NHS activities in England. Anyperson not employed by the NHS, or who is working for the NHS outside England, who wishes to download / copy NPC materials for purposes other than their personal use should seek permission first from the NPC. Email: copyright@npc.nhs.uk Copyright 2008