Non medical prescribing in multiple sclerosis: where does it fit into practice

Linda RenfrewMS Trust Conference 2014

Fit with current policy Evidence for non medical prescribing Prescribing options for AHPs My prescribing journey Integrating prescribing into MS physiotherapy

practice Case Studies Impact on patient care, clinical practice and

service development Thinking about prescribing: things to consider

Key health care policy drivers call for: a shift from acute, hospital-driven services to

community - treating people faster and closer to home

meeting the needs of the ageing population and rising incidence of long-term conditions

encouraging health improvement and “wellness” by supporting people with long-term conditions to self manage their condition

developing services that are proactive, modern, and safe

Non medical prescribing is about

enabling quick, safe and equitable access to medicines for patients.

increasing the kinds of services accessible health professionals (NMAHPs) can deliver.

improving quality-of-care, reducing health inequalities and opening access to services for all.

improving patients’ experiences of services and contributing to better outcomes.

A safe prescription (Scottish Government, 2009)

Efficiency

Improved speed & convenience of treatment (Ball, 2009; Drennan et al, 2009, jones et al, 2010; Oldknow et al, 2010).

Reduced waiting times & increased efficiency of appointments (Courtenay et al, 2011; 2010; Page et al, 2008).

Doctors make better use of their time to treat more complex patients (Carey et al, 2010b; Daughtry and Hayter, 2010).

Patient Experience

Patients were highly satisfied with, and confident in, NMP’s abilities (Courtenay et al, 2011; 2010 Jones et al, 2010; Watterson et al, 2009).

Safety

Patient safety improved (Carey et al, 2009a; Courtenay et al, 2009a).

Medication errors were significantly reduced in diabetic management with a nurse prescriber (Carey et al, 2008; Courtenay et al, 2007).

Nurse prescribers were cautious in prescribing & recognised budgetary restraints ( Watterson et al 2009).

Only 1 adverse incident reported since 2006 No evidence specifically on AHP prescribing

No prescription required Patient Specific Direction(PSD) Patient Group Direction (PGD)

Prescription required Supplementary Prescribing Independent prescribing

“physiotherapists who have not passed an approved prescribing course must not advise patients to take or stop taking medication, or change their dose or type of painkillers, even paracetamol” (CSP 2006)

Legally we need to demonstrate our competency to give advice about medications and that we are working within scope of practice.

Scope of practice

No automatic transfer to new role Scope of profession Working within clinical governance framework of employer Professionally responsible for own actions Accountable to employers and regulatory bodies for actions Easy access to primary patient record, timely communication

with GP Informed consent No unlicensed medicine, limited prescribing of CD’s “Off license/off label” or mixing of medicines undertaken with

strong justification /evidence given Within own caseload

Using a medicine outside its licensed indications/UK marketing authorisation

Only prescribe ‘off-label’ where it is accepted clinical practice.

Local policies for the use of off-label medicines should be approved

Many drugs used in MS are used off label

e.g Gabapentin, Amitriptyline, Amantadine etc.

No other licensed medicine will meet the patient’s need

If a licensed medicine is not available There is sufficient evidence to demonstrate

safety and efficacy Take full responsibility for prescribing, follow

up and monitoring (or ensure GP does). Patient informed re the unlicensed aspect of

medicine

HCPC registered, minimum of 3 years, identified need & support from employer

Non-medical prescribing programme

Joint NMAHP course

40 credits @ level 9 ( 6 months), 20 credits @ level 11( 5 months)

Funded by Scottish Government

26 theory days or 10 days blended learning(+ 10 study days)

78 hours of supervised practice

Exam, examination of practice & portfolio of competencies

NMC/HCPC register annotated Added to local health board register Part of PDP supported by audit of practice

1986 - BSC physiotherapy 1995 - 2005 Senior Neurological out- patient

physiotherapist 2001 - 2005 MPhil in MS 2006 – 3 year ESP post in MS ( part funded

MS soc). Drive to demonstrate added value & improve patient pathways - NMP

2007/8 – NMP(supplementary prescribing) 2009 – secured permanent post – consultant

physiotherapist in MS SP integral to role

Physio led MS review clinics

AHP rep on NMP group NHS A&A 2014 – SP/IP conversion course 2014 – consultant in rehabilitation medicine

retired ( currently unable to recruit to post)

First AHP prescriber in NHS Ayrshire & Arran. ? other AHP prescribers in MS nationally No national or local AHP prescribing a guidelines Discussions with prescribing leads re prescribing

pathway demonstrate how patient care is enhanced

alleviate concerns re prompt communication with GP

alleviate concerns re inappropriate prescribing Liaised with other AHP prescribers re pathways Undertook audit of prescribing practice

Types of medications Numbers of patients -

where, how often Details Costs

0

5

10

15

20

25

30

35

40

45

50

MS clinic Physio Dom visit Total

Total SP

0

1

2

3

4

5

Numbers ofpatients

Musclerelaxants

NSAID

Neuro pain

AB

Bowel med

Patient Details of prescription Cost ( 4 weeks) (based on BNF March

2007 prices)

1 7 day course of trimethoprin £1.35

2 Increase Tizanadine from 18mg – 36mg Approx x100tabs extra £40.00

3 Increase Baclofen from 10mg to 15mg Approx 14 extra tabs £1.80

4 Increase Lactulose from 30 ml to 75ml Additional 1260ml £10.50

5 Increase gabapentin from 2.1g to 2.7g Additional 56(300mg) tabs £4.00

6 Start gabapentin 300mg day 1, 600mg day

2, 900mg day 3.

81 (300mg) tabs £5.40

7 Start ibuprofen 400mg x 3 daily 84(400mg) tabs £6.85

8 Start diclofenac 25mg x 3 daily 84(25mg) tabs £2.42

9 Start clonazepam 1mg increasing to 4mg at

night

56 (2mg) tabs £2.93

10 Start Baclofen 30mg daily 84 (10mg) tabs £2.55

Total £77.80

How? Agreement re prescribing pathway (Nov 2008)

Mirrors traditional out-patient prescribing arrangements in secondary care. Specialist makes recommendations to the GP

Assess, determine need, advise to GP using out-patient notice ( & follow up letter). Personalised stamp

GP writes prescription

Initially as SP within limits of a CMP guiding prescribing

Autonomous prescribing decisions now as an IP

Agreed date for review (in person or phone) and further amendments communicated to the GP

Pt attends physio & needs to start spastcity medicationPt attends physio, assessed & needs to start spasticity medication

Appointment with consultant at clinic

Pt sees consultant & letter sent to GP re medication

Pt makes an appointment with GP & prescription issued

Pt starts medication

Pt reviewed by physio & requires an dose

DELAY 2-6wk

DELAY 2-4wk

DELAY1-3 wk

DELAY

Pt attends physio prescriber , assessed & needs to start spasticity medication

OP advice note issued to GP

GP initiates prescription - pt starts medication

Pt reviewed by physio within agreed timeframe

and dose altered

Final dose of medication notified to GP

Where & when?

Physiotherapy new and review clinics

FES clinic

Domiciliary visits

MS review clinic

Over the phone▪ where initial assessment

has been undertaken

▪ for symptoms such as pain and fatigue

What? Symptomatic treatment

Pain (musculoskeletal and neuropathic)▪ paracetamol, NSAID’s, opiates, compound preparations( co-

codamol), amitryptaline, duloxatine, gabapentin, pregabalinetc

Spasticity( inc management of constipation acting as a trigger factor)▪ baclofen, tizanadine, dantrolene, gabapentin, clonazepam,

sativex (??), movicol, fibrogel, lactulose, anti-biotics Fatigue and management of secondary factors impacting on

fatigue ▪ amantadine

More unusual symptoms▪ tremor▪ hypersalivation

Evidence, local & national guidelines Licencing and legal considerations Local governance and policy arrangements Risks and benefits

Medical History

Drug interactions and side effects

Compliance & concordance▪ Informed consent

▪ Titration & dosing regimes

▪ Impact of psychosocial factors, values & beliefs

▪ Cognition

NICE 2014 – MS pharmacological management Fatigue

Amantadine recommended 8 studies ( 6 Amantadine, aspirin, paroxetine) low to moderate

evidence Spasticity

Ist line baclofen or gabapentin or combine 2nd line tizanadine or dantrolene Benzodiazepines ( nocturnal spasms) Sativex not recommended 33 studies low quality evidence

Tremor 4 studies ( ioniazide, baclofen, botox) evidence inconclusive No recommendations made

NICE 2013 Neuropathic pain

1st line consider amitriptyline, duloxetine, gabapentin ( al off label) or pregabalin

2nd line tramadol for acute rescue therapy

3rd line Capsaicin cream for localised neuropathic pain

Trigeminal Neuralgia

▪ Carbomazapene of phenatoyin

Amantadine Hydrochloride licensed for: Parkinson's disease, antiviral off label for fatigue in MS

Gabapentin licensed for: monotherapy & adjunct treatment for

focal seizures, peripheral neuropathic pain off label prescribing for central neuropathic pain and

spasticity Amitriptyline Hydrochloride

licensed for: depression off label for neuropathic pain

Governance Systems in place to report and respond to "near misses", errors

and adverse drug reactions ( local & national) Rapid access to medical history, current medication and

kidney/liver function to prescribe effectively and safely. Appropriate mentoring, supervision and line management Effective scrutiny of prescribing practice ( audit & quality

monitoring) Strong leadership of non medical prescribing at board level

Policy Local medicines management policy includes NMAHP prescribing NMAHP prescribing policy developed by a multi-disciplinary group

and reviewed regularly

48 year old lady diagnosed with RRMS 10 years ago.

Attending FES review clinic. Is currently taking

copaxone, amantadine (100mg) and co-codamol ( minimal effect on pain).

Ongoing problems with fatigue worse over past 4 months and increased lower limb neuropathic pain affecting sleep. Her mood is low.

Previously tried amytriptyline (25mg) with no effect.

PMH: mild heart arrhythmia

Assessment : lower limb & spinal examination, VAS for pain, FIS & HAD

Diagnosis : neuropathic pain and low mood impacting on sleep contributing to increased fatigue

Considerations: PMH, drug interactions, off label prescribing, concordance

Possible options: increase dose of amantadine ( from 100mg to 100mg bd) restart amitriptyline and titrate dose from 25mg up to

75mg (depending on response). Caution due to heart arrhythmia.

trial gabapentin if no/partial response to amitriptyline . Titrate dose slowly and monitor response

Discuss mood with GP/refer to MS psychologist discuss fatigue management strategies

46 year old man with MS and spinal problems. Wheelchair user but usually independent.

Long history of neuropathic pain and lower limb spasticity( 20 years)

Referred to physiotherapy because his legs feel stiffer,he is falling to the right and forward and now unable to self propel or feed self.

Current medication:60mg baclofen, 36mg tizanadine, 150mg dantrolene and 1800mg gabapentin for past 4 years. GP recently stopped Acupan for pain and started dihydrocodine.

PMH: ↑BP- minoxidil

Assessment: lower limb spasticity ( Ashworth 1/2), L/L ROM -reduced muscle length hamstrings and gastrocnemius. Poor posture, reduced trunk tone and poor control in sitting. U/L tone low with muscle weakness

Diagnosis: anti spasticity medication is causing additional muscle weakness in upper limbs and trunk

Considerations: PMH, drug interactions, avoid abrupt withdrawal Options

gradually reduce & stop one of her AS meds & review impact on L/L spasticity and trunk stability

refer to physio to address trunk stability and reduced muscle length

refer to bioengineering clinic for review of wheelchair refer to OT to review U/L function and additional aids to assist with

eating

38 year old man with advanced MS. Poor cognition, wheelchair bound, poor swallow,PEGfed, marked upper limb and trunk tremor, requiring 24 hour care.

Attended the MS review clinic with mum and carers-main issue is excessive drooling causing him to choke on saliva.

Medication –hyoscine hydrobromide patches changed every 3 days and propranolol (60mg)

Diagnosis: progression of condition requiring management of excessive salivary secretions Considerations: capacity and compliance, drug interactions, scope of practice, withdrawal

of meds Options:

increased frequency of change of patches amitriptyline glycopyrrolate– required further information from MIU on unlicensed application for

use via enteral feeding botox into salivary gland

Outcome no additional benefits noted changing patches daily & significant respiratory side

effects noted. following reaction it was decided not to start glycopyrrolate due to possibility of similar

serious side effects. amitriptyline started (25mg) – no response therefore gradual titration to 75mg.

Increased drowsiness and negative affect on transfers noted. Titrated down and stopped.

referral to head and neck surgeon made for consideration of Botox injection CMP set, close liaison with consultant , GP and mum/carers

Improved patient pathway avoiding multiple appointments with consultant and GP avoiding delays in starting and titrating medication

Optimal symptomatic management optimising combined use of medication and physical

treatments limiting use of medication where not necessary

Seeing the right person with the right skills at the right time The MS physiotherapist has expert knowledge and skills to

assess and prescribe for pain and spasticity and to evaluate the impact of treatment

Improved concordance Physiotherapists spend more time with the patient allowing

opportunities for discussion, improving adherence and patient safety, reducing waste and improving outcomes (NICE 2009)

AHP led MS review clinic

rehab consultant only sees pts requiring medical review

freeing up time for rehab consultant to focus on other areas of service development

longer appointment slots for review appointments

patients as satisfied/more satisfied with new clinic

targets for annual review now being met

Comprehensive initial assessment Consider impact of prescribing decisions &

accountability Independent & joint decision making Extending treatment options & refinement of

treatment combinations Insight into professional strengths of other

disciplines ( nursing, pharmacy 7 medicine) Understanding the bigger picture

Symptom management clinics

spasticity ( combine with botox)

Pain

Relapse management Medicines management at ward review Clinical lead role?

Would prescribing enhance patient care?

Within a service

▪ what, how often and where would prescribing be done?

▪ Are there other professions within the team who would/could take this role on?

As an individual

▪ what is your role & function within the service/team?

▪ is there a need for you to initiate new medications, titrate & alter medications? Where is your service based and is this likely to change ?

Primary or secondary care

Cost codes linked to prescriptions

Communication with GP & access to up to date prescribing summary essential What is the impact of IP training on service delivery and how would thi be managed within

the service What are your clinical governance structures to support prescribing?

A safe prescription ( Scotland) (2009) http://www.scotland.gov.uk/Resource/Doc/286359/0087194.pdf

National Prescribing Centre: A single competency framework for all prescribers (2012) http://www.npc.nhs.uk/improving_safety/improving_quality/resources/single_comp_framework_v2.pdf

HCPC Standards for prescribing ( 2013) http://www.hpc-uk.org/assets/documents/10004160Standardsforprescribing.pdf

Practice Guidance for Physiotherapist Supplementary and/or Independent Prescribers in the safe use of medicines (CSP, 2013)