The Health Innovation Network Polypharmacy programme is working with healthcare professionals to address problematic polypharmacy by supporting easier identification of patients at potential risk from harm from multiple medications. Our evidence-based polypharmacy Action Learning Sets (ALS) are being rolled out across England to support GPs, pharmacists and other healthcare professionals who undertake prescribing or medication reviews to understand the complex issues around stopping inappropriate medicines safely. To drive and accelerate changes in practice, delegates complete a quality improvement project to address problematic polypharmacy in their workplace. This poster summary, Review of gabapentinoid prescribing, can be viewed here. For more information about the polypharmacy programme, please visit https://thehealthinnovationnetwork.co.uk/programmes/medicines/polypharmacy/

1. Review of gabapentinoid prescribing
Helen Hulme, Clinical Pharmacist, Hannage Brook Medical Centre; Associate Director, South Dales PCN
Gabapentinoids are recommended as an option in the management of neuropathic pain with evidence suggesting
only around a third of patients benefit, and even those that do see their pain reduced on average by 50% 1
NICE guidelines state that gabapentinoids should not be used for chronic pain, for lower back pain or sciatica 2,3
Patient safety concerns related to the use of gabapentinoids include risk of developing dependence, potential for
drug withdrawal, and a spectrum of side effects from somnolence, dizziness, gait disturbance, peripheral oedema,
and sexual dysfunction to severe respiratory depression.
Based on these factors, Public Health England made various recommendations including 4 :
• Patients who are offered gabapentinoids need to have sufficient information on the clinical effectiveness and
related risks to consent to the treatment plan.
• If a decision is made to prescribe gabapentinoids for unlicensed indications, the rationale should be discussed
with the patient, appropriate consent acquired, and all discussions clearly documented.
Hannage Brook is the highest prescriber of
gabapentinoids in the PCN and our use is increasing
This review was undertaken as part of the 2022/3
QOF QI work on drugs of dependence.
As a practice we agreed to :
- Review the indication for prescribing and
documentation around shared decision making
- Offer patients a medication review to discuss
the benefits and harms of continuing treatment
Review of initiation of gabapentinoids
35 patients started gabapentin or pregabalin
between November ‘22 and March ‘23.
25 patients reviewed – all prescriptions were acute
• Age range 16-89 years old
• 10 started by GP, 7 by locum, 5 by pharmacist
(3 from letters), 2 by registrar
• 32% had documented discussion re side effects
• 8% had discussion re dependence at start. Further
8% at review. Only documented by pharmacists
• 44% not ordered again since initial prescription
Age Started by Indication Side effects Dependence Acute/repeat Notes
74 Pharm Cancer pain y A Teminal diagnosis
16 GP Headache y A Awaiting paeds
80 Locum OA hip A One off
55 GP Red scrotum syndrome A Ineffective
88 Registrar Leg pain A
89 Registrar Shingles A
56 Locum Scapular pain A
69 GP Neuropathic pain A One off
41 GP Wrist pain A Limited options
85 Hospital Generalised pain ? A Limited options
63 GP Neuropathic pain A Limited options
53 Locum Back pain, stabbing pain when walks y A One off
58 GP All over body pain A One off
38 Pharm Sciatica type pain y y A
71 GP Electric shock pain in gums y A One off
78 Locum Back pain y (pharm rv) A
31 Locum Tight feeling in leg A then R
50 Pharm Ovarian cancer (from letter) A One off
66 Hosp letter - pharm start Diabetic neuropathy y y (pharm rv) Now on NSAID
73 GP Shingles y (review) A
72 Locum Hip pain A Dx PMR
89 GP Thigh pain A
75 GP Abdo pain (tingling) A One off
55 Locum Carpal tunnel A
61 Hosp letter - pharm start Pelvic pain (urology advice) y y A One off
Medication review of gabapentinoids
What did we do?
• Education session with local physio specialising
in supporting people with chronic pain. Enabled
us to understand local services
• Sampled how we might offer medication
reviews in targeted way
• Developed AccuRx Florey questionnaire as
“screening” tool
• Produced patient information leaflet to send to
patients prior to review
• Review of medical notes for suitable patients
(excluded new starts, complex, under pain clinic)
Results
30 patients prescribed gabapentinoid reviewed:
5 excluded from invites at this stage
4 not ordered for some time so stopped
5 called in as dose too high for renal function
Further 10 sent an AccuRx and leaflet
- 6 accepted via AccuRx reply
- 3 trial dose reductions
- 2 awaiting operations; reminder for later review
- 1 already taking lower dose. Review in 3 months
62% of patients had an intervention (13 out of 21)
Positive experience for patients and pharmacist
Action and learning points
✓ Education session for all prescribers on recent guidelines and audit work
✓ Aim for improvement when we initiate gabapentinoids:
- retain as acute prescriptions so we can review ongoing prescribing
- better documentation around risks and benefits
- greater evidence for shared decision
✓ Focus on function rather than pain management. What does continuing allow that person to do?
- realistic expectations when initiate, stop if not working
✓ Patient information leaflet in place to share with patients
✓ Need for continuity of message and of the person involved with reduction “journey”
✓ Agreed as priority area for SMRs in 2023/24
- continue same targeted invitations but adapt if needed
✓ Reaudit planned for December 2023
References
1. NICE, CG173: Neuropathic pain in adults: pharmacological management in non-specialist settings, 2013(last updated 2020)
2. NICE, NG59: Low back pain and sciatica in over 16s: assessment and management, last updated December 2020
3. NICE, NG193: Chronic pain (primary and secondary) in over 16s: assessment of all chronic pain and management in chronic primary pain, April 2021
4. Stanard et al. Advice for prescribers. Stanard et al. Advice for prescribers on the risk of the misuse of pregabalin and gabapentin, NHSE & PHE, 2014