Professional Clinical Network Pharmacy Forums

September 2023

Recording of the monthly Pharmacy Forum from The Medicines Optimisation Team followed by presentation on Electronic repeat dispensing Turarpi and Blood Glucose Testing Strips Update.

May 2023

Monthly update from The Medicines Optimisation Team followed by presentation on Medicines Quality

Information from the CQC website with regards to high- risk drugs etc .

GP mythbuster 12: Accessing medical records and carrying out clinical searches – Care Quality Commission (cqc.org.uk)

These are examples of the search categories we are currently using.
It is not a full list, and we will update it periodically.

You will need to provide assurance in line with the following areas:

1. Monitoring patients prescribed DMARDs See Specialist Pharmacy Service (SPS) guidance on drug monitoring.

• Azathioprine monitoring
• Leflunomide monitoring
• Methotrexate monitoring

Also see NICE Clinical Knowledge Summary (CKS) for DMARD monitoring

2. Medicines requiring monitoring: NICE CKS and specific data sheet/licensing requirements

• ACE (angiotensin converting enzyme) inhibitor or ARB (angiotensin receptor blocker) monitoring
• Aldosterone Antagonist monitoring
• Amiodarone monitoring
• Direct oral anticoagulants (DOAC) monitoring
• Lithium monitoring
• Metformin with eGFR less than 30
• Warfarin monitoring

1. MHRA/Central Alerting System (CAS)/drug safety updatealerts to check provider has taken appropriate action in response

a) Single drug alerts:

• Citalopram greater than 20mg or escitalopram greater than 10mg in patients aged over 65: ventricular arrhythmia risk
• DOAC and mechanical valve
• Febuxostat: cardiovascular risk
• Fentanyl patch and no recent opioid prescriptions
• Hydrochlorothiazide: skin cancer risks
• Mirabegron BP monitoring
• SGLT-2 inhibitors: Fournier’s gangrene risk and diabetic keto acidosis risk
• Valproate, valproic acid, carbimazole, modafinil, topiramate and pregabalin: teratogenicity risk

b) Combination drug alerts:

• Clopidogrel and omeprazole or esomeprazole: reduced antiplatelet effect
• Potassium sparing diuretic and ACE or ARB monitoring
• Renin-angiotensin system drugs on two or more: increased renal risk
• Simvastatin 40mg or more and amlodipine, diltiazem or verapamil: increased myopathy risk

4. Potential missed diagnosis:

• Repeated raised HbA1c greater than 47 on at least 2 occasions and no coded diagnosis of diabetes. See NICE CKS diagnosing diabetes.
• Chronic kidney disease (CKD) stage 3-5 (See NICE CKD diagnosis chronic kidney disease):
  • repeated reduced eGFR less than 60 in the last 2 years (including the latest), and
  • no coded diagnosis of chronic kidney disease.

5. Medicines usage:

• Number of asthmatic patients issued more than 12 Short Acting Beta 2 Agonist (SABA) inhalers in the last 12 months. See Why asthma still kills 2014.
• Prescribing gabapentinoid medicines where review is indicated.
• Prescribing benzodiazepine and ‘Z’ drugs and where frequency of issue warrants investigation.
• Prescribing a non-steroidal anti-inflammatory drug or antiplatelet to a patient aged over 70 without a proton pump inhibitor for gastrointestinal protection
• Prescribing a long acting beta agonist (LABA) inhaler to an asthmatic patient (excluding COPD) in the past 6 months with no inhaled corticosteroid prescribed
• Patients with atrial fibrillation and a recorded CHADSVASC2 score greater than or equal to:
  • 1 if male
  • 2 if female
    with no anticoagulant prescribed
• Combined oral contraceptive pill prescribed to patients with a history of venous thromboembolism

6. Medication review

• Identifying all patients who have had a medicines review in the last 3 months to assess quality of the review process (all ages and over 75 years).
• Identifying patients receiving 10 or more medicines who have no medication review recorded in the past 18 months

7. Monitoring of high-risk patients with long-term conditions:

• Patients with chronic kidney disease (CKD) stage 4 or 5 who have not had a urea and electrolytes (U+E) test in the last 9 months
• Patients with diabetic retinopathy with latest HbA1c greater than 74mmol/l
• Asthmatic patients prescribed 2 or more courses of oral steroids in the last 12 months
• Hypothyroid patients who have not had a thyroid stimulating hormone (TSH) test in the last 18 months.

8. We may also look at:

• Patients who have had a DNACPR or ReSPECT form completed in the last 2 years
• How patients have accessed different types of appointments in recent months.