NSAIDs AUDIT IN PRIMARY CARE

1. NSAIDs AUDIT IN PRIMARY CARE GPST1 Marie Birchall

2. Aim • Safe Prescribing with NSAIDs, taking into account GI risk factors and CVS risk factors, in accordance with NICE and MeRec guidelines.

3. Objectives • To identify how many people >65 yrs of age are on an NSAID • To identify those who are on an NSAID and >65 are on PPI • To identify which NSAID is most popular and is the preferred choice. • To identify if we are prescribing NSAIDs to patients with ischaemic heart disease • To identify which type of NSAID is mostly prescribed for those with ischaemic heart disease.

4. Method • Looked at patients within 6 month period- from 7/12/11- 7/6/12. • Used “Clinical Reporting tool” in system one to help filter out data according to criteria. • Criteria: • Patients >65yrs on Diclofenac • Patients >65yrs on Naproxen • Patients >65 yrs on Ibuprofen • Patients with IHD on Diclofenac • Patients with IHD on Naproxen • Patients with IHD on Ibuprofen • If above on repeats • If above on PPI • Any significant events i.e gastrointestinal bleed and MI when on NSAID

5. NICE Guidelines • Paracetamol and/or topical NSAID should be considered ahead of oral NSAID. • If paracetamol or topical NSAIDs are ineffective for people with OA, substitute with oral NSAID/COX-2 inhibitor. • All oral NSAIDs/COX-2 inhibitors vary in their potential GI, liver and cardio-renal toxicity. Should take into account individual patient risk factors, inc age. When prescribing these drugs, consideration should be given to appropriate assessment and/or ongoing management of these risk factors.

6. NICE Guidelines cont. • Oral NSAIDS should be used at the lowest dose for shortest possible time. • If person on aspirin, should consider other analgesics before substituting or adding NSAID or COX-2 inhibitor (with PPI) if pain relief ineffective/insufficient. • Offer analgesics (egparacetamol, codeine, or compund analgesics) to people with RA whose pain is not adequate to reduce their need for long term tx with NSAIDs or COX-2 inhibs. • Should co-prescribe NSAID with PPI.

7. MeReC- National Prescribing Centre • Increased risk of death or recurrent MI with NSAIDs in patients with prior MI. Highest risk was assoc with diclofenac, lowest risk with naproxen. • Consider prescribing PPI with any NSAID to reduce GI effects, partic in those who are at risk (inc >65 yrs) and long term NSAID users. • Among traditional NSAIDs- diclofenac seems to be associated with highest (and Naproxen the lowest) risk of CV events. • Recommends low dose ibuprofen < 1200mg/day and naproxen 1000mg/day

9. >65 yrs co-prescribed PPI with NSAID in last 6 months 54 %

10. >65 yrs with NSAIDs on their repeats

11. Patients taking NSAIDs with IHD in last 6 months

12. Significant events • No patient had MI in last 6months whilst on NSAID • No patient had GI bleed in last 6 months as a result of NSAID prescribing

13. Conclusion • Naproxen seems to be preferred choice of NSAID which correlates with guidelines. • Only 51% of patients over 65 yrs on NSAID have been prescribed PPI. • Significant proportion of patients have oral NSAIDs prescribed on repeats. • Naproxen seems to be drug of choice when prescribing in those with IHD as recommended by current guidelines. • However, results suggest patients with IHD are receiving diclofenac on repeats which is known to increase CV risk with PMH of IHD.

14. Limitations • Small patient number. • Not all NSAID preparations included in this study. • Only looked at 3 traditional NSAIDs- Diclofenac, Naproxen and Ibuprofen. • Only looked at IHD- not included other read codes eg stroke. • Does not look at other GI risk factors when considering NSAIDs. • Not looked at duration of NSAID • Not looked at dose of NSAID

15. Recommendations • Cont to use Naproxen as first choice or low dose ibuprofen as recommended in NICE and MeRec guidelines • Avoid using diclofenac if possible. • Prescribe PPIs in >65 yrs who are on NSAID • Avoid adding NSAIDs to repeats/closer monitoring and patient education needed.

16. Thank You !!