Deprescribing

Question 1

what are the RCGP curriculum prescribing points

Answer 1

1. safety- avoiding injuries to patients from care that is intended to help them
2. timeliness- reduce waits and sometimes harmful delays for both those who receive and those who give care
3. effectiveness- providing services based on scientific knowledge to all who could benefit
4. efficiency- avoiding waste, including equipment, supplies, ideas and energy
5. equality- providing care that doesn’t vary in quality because of personal characteristics
6. person centred- providing care that’s respectful and responsive to individual patient preferences, needs and values

Question 2

what is the care quality commission

Answer 2

1. essential organisation into checking a GP practice is prescribing safely and effectively
2. targets different things based on changeable priorities
3. common themes of medication types looked at
4. can be difference between practice passing an inspection or requiring extra measures
5. implications if no safe and effective processes in place

Question 3

what are the 10 principles of good prescribing

Answer 3

1. be clear about reasons for prescribing
2. take into account patients medication history
3. take into account other factors that might alter benefits and risks of treatment
4. take into account patients ideas, concerns and expectations
5. selective effective, safe and cost effective medicines individualised for patient
6. adhere to national guidelines and local formularies
   7.write unambiguous legal prescriptions using correct documentation
7. monitor beneficial and adverse effects of medicines
8. communicate and document prescribing decisions and reasons
9. prescribe within limitations of your knowledge

Question 4

what is a medication error

Answer 4

a patient safety incident where there has been an error in the process of prescribing, preparing, dispensing, administering, monitoring or providing advice on medicines

Question 5

what are prescribing errors

Answer 5

involves decision around the treatment, the physical or electronic prescription and follow up or monitoring

Question 6

give examples of influences on prescribing safely and how these may be overcome

Answer 6

1.social media and pils- talk about likelihood of side effects
2. patient expectations- medication reviews

Question 7

give examples of berries to pressuring and how these may be overcome

Answer 7

1. stock issues- alternatives and communications
2. swallowing difficulties, size of tablets- leaning on MDT, doubling dose and lower strength smaller tablets

Question 8

give examples of what should be monitored in patients medication

Answer 8

1. adherence- Intentional and non intentional
2. blood tests- renal impairment
3. overuse- opioids
4. annual review or more frequent if needed
5. shared care agreement from specialist in place
6. drug alerts and formulary changes
7. dose adjustments

Question 9

what are the key groups of medications to target monitoring

Answer 9

1. DMARDs- methotrexate, sulfasalazine
2. DOACs- apixaban
3. opioids
4. NSAIDs
5. insulin
6. ACEi/ARBs
7. diuretics
8. anticholinergics- amytriptilline
9. benzodiazepines
10. Z drugs- zopiclone, zolpidem

Question 10

what prescribing targets are used at a practice level

Answer 10

1. quality outcomes framework
   - mainly condition focussed but can also have targets associated with prescribing
   - quality improvement indicator regarding dependence forming medications

Question 11

what prescribing targets are used at a PCN level

Answer 11

1. impact and investment fund
   - multiple targets announced each year with priorities
   - ensure targeted groups of patients receive appropriate care through reviews, monitoring and prescribing

Question 12

what may lead to changes in prescribing practices

Answer 12

1. audits
2. meetings
3. MDT
4. significant events
5. risk stratifying

Question 13

what are green prescribing initiatives

Answer 13

• medicines account for 25% of emissions within NHS
• prescribing greener inhalers helps NHS to achieve net zero target

Question 14

how is cost effective prescribing achieved

Answer 14

1. ensure generic and not branded where possible
   - some patients may specify brand but lean them towards generic if no clear reasoning
2. little evidence that branded products are better
3. reduce medicine wastage and ask patients if they really require PRN items
4. encourage self care and OTC treatment rather than prescription for minor ailments

Question 15

describe what is involved in medication reviews

Answer 15

1. history- discharges, let’s, compliance, OTC
2. monitoring- bloods, shared agreements in place, annual bP, weight needed if on DOAC in last 12 months, Crcl
3. indication for every drug
4. historic medication removed from repeat
5. reauthorise all medication for a year if happy
6. allergies documented on home screen to prevent future errors

Question 16

describe what is involved in a structured medication review

Answer 16

more in depth review, targeting specific groups of patients
1. patients in care homes
2. patients with complex and problematic polypharmacy, 10 or more medications
3. patients on medications commonly associated with medication errors
4. patients with severe frailty who are isolated or housebound, or who have recent hospital admissions or falls
5. patients using potentially addictive medications

Question 17

what is the NO TEARS tool in deprescribing

Answer 17

N- need and indication checked
O- open questions asked
T- tests and monitoring done
E- evidence and guidelines checked
A- adverse events checked
R- risk reduction or prevention
S- simplification and switches checked

Question 18

what is the benefit of deprescribing opiates

Answer 18

1. evidence shows hyperalgesia in over 120mg oral morphine equivalent
2. reduction can sometimes help relieve pain
3. reduces side effects and likelihood of overdose
4. multiple opioids on repeat is dangerous

Question 19

how is multi professional collaboration used in improving prescribing

Answer 19

1. uses shared consultations
2. lean on increasing support of other roles
3. regular reviews to maintain patient confidence
4. back up with evidence based decisions
5. pain clinic involvement sometimes helpful to back up decision making