Key therapeutic topics– Medicines
management options for local implementation
April 2012
Version 4.2
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Foreword
I am delighted to welcome the latest update of the National Prescribing Centre’s Key
therapeutic topics – Medicines management options for local implementation. With
this update, we include data describing the excellent progress made on the original
15 topics.
As mentioned in the July 2011 edition of this document, the NPC, the NHS
Information Centre and the NHS Prescription Services of the NHS Business Services
Authority (NHS RxS) have developed comparators to help you monitor these topics.
The data from September 2010 to September 2011 are shown on the graphs on the
next page of this document. The progress is very encouraging; for example, as a
result of changes in the prescribing of NSAIDs it is likely that this translates into
1,000 fewer premature or avoidable cardiac events in England each year.
This update of the ‘Key Therapeutic Topics’ document contains revised options in
light of the progress made in some of these areas, but also around changing
circumstances and priorities. After a significant volume of feedback from both the
NHS and partner organisations, we have ‘retired’ four topics (alendronate,
clopidogrel, orlistat and PPIs), while introducing five new ones aimed at further
improving prescribing quality and safety. These are:
•
•
•
•
•
Laxatives
First-choice antidepressant use in adults with depression or generalised anxiety
disorder
Three-day courses of trimethoprim for uncomplicated urinary tract infection
Minocycline
Wound care products
We have retained the other topics and updated them in the light of new guidance and
important new evidence. We have also combined some sections to create two new
ones - ‘type 2 diabetes mellitus’ and ‘lipid modifying drugs including ezetimibe’.
Thank you once again for your continuing hard work in the pursuit of high quality
prescribing and medicines management.
Yours sincerely
Clare Howard
QIPP National Lead Medicines Use and Procurement
Useful links:
1. NHS Prescription Services’ QIPP Prescribing Comparatorswww.nhsbsa.nhs.uk/PrescriptionServices/3332.aspx
2. NHS Information Centre Indicators, Comparators and the Prescribing Toolkit,
including QIPP comparators – www.ic.nhs.uk/services/prescribing-support-unitpsu/using-the-service/reference/indicators-comparators-and-the-prescribingtoolkit-including-qipp-comparators
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National QIPP Prescribing Comparators.
Mean is of 151 PCTs. Bars link the lowest to highest PCT comparator values.
ACE Inhibitor % items
Clopidogrel generic prescribing rate
80
78
76
74
72
70
68
66
64
62
60
MEAN
Sep-10
Dec-10
Mar-11
Jun-11
100
99
98
97
96
95
94
93
92
91
90
Sep-11
MEAN
Sep-10
Dec-10
Quarter to
Mar-11
Jun-11
Sep-11
Quarter
Low cost lipid modifying drugs
Antibacterial items/STAR PU
0.50
90
0.45
85
0.40
80
0.35
MEAN
75
MEAN
0.30
0.25
70
0.20
65
0.15
60
0.10
Sep-10
Dec-10
Mar-11
Jun-11
Sep-11
Sep-10
Dec-10
95
90
MEAN
85
80
75
70
Dec-10
Mar-11
Jun-11
Sep-11
Cephalosporins & quinolones % items
Hypoglycaemic agents
100
Sep-10
Mar-11
Quarter to
Quarter to
Jun-11
20
18
16
14
12
10
8
6
4
2
0
MEAN
Sep-10
Sep-11
Dec-10
Mar-11
Jun-11
Sep-11
Quarter to
Quarter to
Low cost PPIs % items
Hypnotics ADQ/STAR PU
2.50
99
97
2.00
95
MEAN
93
MEAN
1.50
91
89
1.00
87
85
0.50
Sep-10
Dec-10
Mar-11
Jun-11
Sep-11
Sep-10
Dec-10
Quarter to
NSAIDs: Ibuprofen & naproxen % items
Jun-11
Sep-11
Alendronate generic prescribing rate
100
80
75
70
65
60
55
50
45
40
35
30
25
99
98
MEAN
MEAN
97
96
95
94
93
Sep-10
Dec-10
Mar-11
Jun-11
Sep-11
Sep-10
Dec-10
Quarter to
1.80
1.60
1.40
MEAN
1.20
1.00
0.80
0.60
0.40
Dec-10
Mar-11
Jun-11
Sep-11
MEAN
Sep-10
MEAN
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s
Mar-11
Quarter to
Dec-10
Mar-11
Quarter to
Long/intermediate insulin analogues
Dec-10
Sep-11
100
95
90
85
80
75
70
65
60
55
50
Quarter to
Sep-10
Jun-11
Alendronate as % of all bisphosphonates
2.00
Sep-10
Mar-11
Quarter to
NSAIDs: ADQ/STAR PU
100
95
90
85
80
75
70
65
60
55
50
45
40
35
Mar-11
Quarter to
Jun-11
Sep-11
Jun-11
Sep-11
Contents
Section 1 .................................................................................................................. 6
KEY THERAPEUTIC TOPICS .................................................................................. 6
April 2012 Update... ....................................................................................................6
Laxatives.................................................................................................................. 7
Options for local implementation........................................................................ 7
Evidence context ............................................................................................... 7
Renin-angiotensin system drugs ........................................................................... 8
Options for local implementation........................................................................ 8
Evidence context ............................................................................................... 8
Lipid modifying drugs including ezetimibe ......................................................... 10
Options for local implementation...................................................................... 10
Evidence context ............................................................................................. 10
High dose inhaled corticosteroids in asthma ..................................................... 13
Options for local implementation...................................................................... 13
Evidence context ............................................................................................. 13
Hypnotics ............................................................................................................... 14
Options for local implementation...................................................................... 14
Evidence context ............................................................................................. 14
Low dose antipsychotics in people with dementia ............................................ 15
Options for local implementation...................................................................... 15
Evidence context ............................................................................................. 15
First-choice antidepressant use in adults with depression or generalised
anxiety disorder .................................................................................................... 17
Options for local implementation...................................................................... 17
Evidence context ............................................................................................. 17
Antibiotic prescribing – especially quinolones and cephalosporins ................ 19
Options for local implementation...................................................................... 19
Evidence context ............................................................................................. 19
Three-day courses of trimethoprim for uncomplicated urinary tract infection. 20
Options for local implementation...................................................................... 20
Evidence context ............................................................................................. 20
Minocycline ........................................................................................................... 21
Options for local implementation...................................................................... 21
Evidence context ............................................................................................. 21
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Type 2 diabetes mellitus ....................................................................................... 23
Options for local implementation...................................................................... 23
Evidence context ............................................................................................. 23
Non-steroidal anti-inflammatory drugs (NSAIDs) ............................................... 27
Options for local implementation...................................................................... 27
Evidence context ............................................................................................. 27
Wound care products ........................................................................................... 29
Options for local implementation...................................................................... 29
Evidence context ............................................................................................. 29
Section 2 ................................................................................................................ 31
QIPP PRESCRIBING COMPARATORS ................................................................. 31
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Section 1- Key Therapeutic Topics
Since the publication of the February 2012 update to ‘Key therapeutic topics–
Medicines management options for local implementation’, a number of
resources have been published to support local implementation of these key
topics.
Three MeReC Bulletins have been published covering:
1. NSAIDs; antibiotics; and high dose inhaled corticosteroids (ICS) in asthma
2. Antipsychotics in dementia; statins and ezetimibe; and hypnotics
3. Type 2 diabetes mellitus
Academic detailing aids can be downloaded from the NICE website for:
•
•
•
•
•
•
High dose inhaled corticosteroids (ICS) in asthma
Long-acting insulin analogues in type 2 diabetes mellitus
Low dose antipsychotics in people with dementia
Minocycline use in acne
NSAIDs
Three day courses of trimethoprim for uncomplicated urinary tract infection
(UTI)
Some minor wording amendments have also been made to this document.
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Laxatives
Options for local implementation
•
•
Review and, where appropriate, revise prescribing of laxatives for adults to
ensure that they are only prescribed routinely for the short-term treatment of
constipation, where dietary and lifestyle measures have proven unsuccessful or
where there is an immediate clinical need.
Laxatives should be prescribed for the treatment of children and young people
with constipation in line with NICE guidance.
Evidence context
Most adults with mild or acute functional (idiopathic) constipation can be managed by
dietary and lifestyle changes. In adults, laxatives should be reserved for cases where
simple interventions have failed, or where rapid relief of symptoms is required.
The evidence for the safety and efficacy of all laxatives is limited. This is mainly
because many laxatives have been in use for a long time and clinical trials were less
frequently conducted when they were first licensed. Few new clinical trials have
been performed, although there are some studies in children and adults which
demonstrate benefits to the quality of patient care with polyethylene glycols over
lactulose. Furthermore, few trials have examined the relative effectiveness of the
general approach options for the management of constipation, such as a combination
of bowel-friendly diet, fluids, exercise, behaviour training, bowel disimpaction
followed by regular laxatives adjusted according to the response.
Prescribing choice (e.g. bulk forming, osmotic and/or stimulant laxatives) mainly
depends on the presenting symptoms, patient acceptability and cost. Prolonged
treatment is seldom necessary, except occasionally in the elderly, in palliative care,
or to prevent recurrence in children.
The NICE guideline on irritable bowel syndrome (IBS) recommends that laxatives
should be considered for the treatment of constipation in people with IBS, but people
should be discouraged from taking lactulose.
NICE recommends prucalopride as a possible treatment for chronic constipation in
women only if they have tried at least two different types of laxatives at the highest
possible recommended doses, for at least six months, and this has not helped their
constipation, and invasive treatment for constipation is being considered.
Healthcare professionals should follow the NICE guideline on constipation in children
and young people. It advises that dietary interventions should not be used alone as
first-line treatment for constipation (as would be the case for adults).
Further information on the management of constipation can be found in a MeReC
Bulletin from January 2011, in CKS guidance (updated September 2010) and, for
children and young people, in the NICE clinical guideline.
A prescribing comparator is available to support this QIPP topic: Laxatives
items/1000 ASTRO-PU.
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Renin-angiotensin system drugs
Options for local implementation
•
Review and, where appropriate, revise prescribing to ensure it is in line with NICE
guidance.
Evidence context
Hypertension, diabetes mellitus, chronic kidney disease (CKD), chronic heart failure
and post-myocardial infarction (post-MI) are the main indications for reninangiotensin system (RAS) drugs, and all of these are covered by NICE guidance.
The therapeutics is therefore complex with multiple indications and the need to
decide in individual patients whether they should take an ACE inhibitor or an
angiotensin receptor blocker (ARB)* and whether there are advantages of an ACE
inhibitor plus an ARB. This evidence has been summarised in the renin-angiotensin
system drugs NPC e-learning materials and in a MeReC Bulletin from March 2010.
ACE inhibitors have a larger evidence base than ARBs. In the NICE guidelines on
chronic heart failure, type 2 diabetes, CKD and secondary prevention post-MI, ACE
inhibitors are the first-line choice ahead of ARBs, when a RAS drug is indicated.
ARBs are an alternative to ACE inhibitors if a RAS drug is indicated but an ACE
inhibitor cannot be used because of an intolerable ACE inhibitor-induced cough.
In the new NICE guideline on hypertension, ACE inhibitors and ARBs were
considered to be equivalent with regard to their effect on clinical outcomes. The
guidance recommends that either an ACE inhibitor or a low-cost ARB could be
offered for non-black people younger than 55 years. MeReC Rapid Review No. 4470
explains the rationale behind this guidance.
The introduction of generic formulations of losartan has resulted in wide variations in
the costs of available ARBs. However, as discussed in MeReC Rapid Review No.
2396, all ARBs may not have identical benefits (for example in heart failure). Before
considering any change in medicines in this class, a careful medication review is
required, applying the relevant, complex evidence-based therapeutics to each
individual patient.
Dual therapy with an ACE inhibitor plus an ARB has only a limited place – for
example, in a small minority of patients with heart failure. The NICE guideline on
chronic heart failure recommends that, following specialist advice, the addition of an
ARB licensed for heart failure is one option that could be considered for patients who
remain symptomatic despite optimal therapy with an ACE inhibitor and a betablocker. Other options include the addition of an aldosterone antagonist licensed for
heart failure, or hydralazine in combination with nitrate.
The NICE guideline on hypertension states that an ACE inhibitor should not be
combined with an ARB to treat hypertension. For secondary prevention post-MI,
NICE states that combining an ACE inhibitor with an ARB is not recommended for
routine use; and in the full NICE guideline on CKD it states that there is no evidence
to suggest increased effectiveness of combining an ACE inhibitor with an ARB over
and above the maximum recommended dose of each individual drug.
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A prescribing comparator is available to support this QIPP topic – ACE inhibitor %
items”: the number of prescription items for ACE inhibitors as a percentage of the
total number of prescription items for all drugs affecting the renin-angiotensin system
excluding aliskiren.
* The term angiotensin receptor blocker (ARB) is synonymous with angiotensin-2
receptor antagonist (A2RA)
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Lipid modifying drugs including ezetimibe
Options for local implementation
•
Review and, where appropriate, revise prescribing of ezetimibe and high cost
statins to ensure it is in line with NICE guidance.
Evidence context
NICE has issued several pieces of guidance relating to lipid modification in adults.
NICE guidance on ezetimibe is referred to in the NICE clinical guideline on lipid
modification and the NICE clinical guideline on type 2 diabetes, and is incorporated
into the NICE clinical guideline on familial hypercholesterolaemia (FH). Key points
from these pieces of guidance relating to use of statins and ezetimibe are
summarised in the algorithm on the next page. See NICE guidance and/or NICE
pathways for further details of who should be offered treatment with statins and/or
ezetimibe and additional or alternative treatment options in these conditions.
A MeReC Bulletin from December 2008 on lipid-modifying treatment is available. It:
- addresses the similarities and differences between NICE guidance for people
with and without type 2 diabetes
- provides clarification on NICE’s recommendations regarding thresholds for
considering whether to intensify treatment
- discusses the evidence base for high-intensity statins, rosuvastatin and
ezetimibe; the reliability of single cholesterol measurements; and the side effects
of statins.
Since the MeReC Bulletin was published, a large meta-analysis has confirmed the
benefits of standard dose statin therapy on cardiovascular (CV) outcomes. It also
suggested additional benefits from more intensive statin therapy in selected high-risk
populations. The meta-analysis and its implications are discussed in MeReC Rapid
Review No. 2127. A more recent, large meta-analysis is discussed in MeReC Rapid
Review No. 2835. It found no statistically significant reduction in all-cause mortality or
CV mortality with intensive statin dosing compared to moderate or low dosing, except
in people with acute coronary syndrome. Importantly, it also did not find a linear
association between reductions in LDL-cholesterol and reductions in the risk of death
from coronary heart disease or non-fatal myocardial infarction.
NICE advises that any decision to offer a higher intensity statin should take into
account the patient's informed preference, including the benefits and risks of
treatment. This is entirely consistent with advice from the MHRA given in the May
2010 edition of Drug Safety Update. The MHRA advises that simvastatin 80 mg daily
should be considered only in patients with severe hypercholesterolaemia and high
risk of CV complications who have not achieved their treatment goals on lower
doses, when the benefits are expected to outweigh the potential risks of myopathy
associated with the higher dose. Myopathy occurs with all statins and the risk
appears to be related to dose. There is no good evidence to suggest that any one
statin has any advantages over another in this regard at a population level.
MeReC Rapid Review No. 1423 discusses the place in therapy of simvastatin 80 mg
daily in the context of the MHRA advice, NICE guidance and the current evidence
base, including the risks from other statins at high doses.
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There remains no published evidence that ezetimibe, alone or added to a statin,
reduces the risk of CV disease or mortality compared with an active comparator (see
MeReC Rapid Review No. 1722). The SHARP study compared simvastatin plus
ezetimibe with placebo in people with chronic kidney disease, and is discussed in
MeReC Rapid Review No. 4270. This study provides no information as to how the
combination would compare to simvastatin 40 mg alone in this indication.
Two prescribing comparators are available to support this QIPP topic, including a
new comparator. The titles of these are:
1. ‘Low cost lipid-modifying drugs’: the number of prescription items for
simvastatin and pravastatin as a percentage of the total number of prescription
items for all statins and ezetimibe, including simvastatin/ezetimibe combination
products.
2. ‘Lipid modifying drugs: ezetimibe % items’: the number of prescription items
for ezetimibe and ezetimibe/simvastatin combinations as a percentage of total
items for all statins and ezetimibe, including simvastatin/ezetimibe combination
products.
The patent on Lipitor (atorvastatin) was originally expected to expire in November
2011. However, a six month extension to the Lipitor patent has been granted,
meaning that Lipitor is now patent protected until May 2012. The initial generic price
of atorvastatin and the pace at which this will fall remain unknown. There are,
therefore, still substantial savings to be made by some NHS organisations through
the use of low cost statins, and prescribing of ezetimibe in line with NICE guidance.
More information on statins, ezetimibe and other lipid-modifying drugs can be found
within the lipids NPC e-learning materials.
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Summary of NICE guidance on use of statins and ezetimibe in adults
This summary is intended only as a guide to certain aspects of the use of statins and
ezetimibe. It is not a comprehensive guide to all aspects of care. See the relevant
NICE guidance and/or NICE pathways for specific details, including who should be
offered treatment, additional or alternative treatment options, referral and monitoring
recommendations, etc.
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High dose inhaled corticosteroids in asthma
Options for local implementation
•
•
Review the use of inhaled corticosteroids (ICS) routinely in patients with asthma.
Step down the dose and use of ICS where clinically appropriate in patients with
asthma.
Evidence context
ICS are the first-choice regular preventer therapy for adults and children with asthma
for achieving overall treatment goals. To minimise side effects from ICS in people
with asthma, the BTS/SIGN guideline recommends that the dose of ICS should be
titrated to the lowest dose at which effective control of asthma is maintained.
Doubling the dose of ICS at the time of an exacerbation is of unproven value and is
no longer recommended.
Prolonged use of high doses of ICS (as with the use of oral corticosteroids) carries a
risk of systemic side effects (e.g. adrenal suppression or crisis, growth retardation in
children and adolescents, decrease in bone mineral density, cataracts and
glaucoma) and a range of psychological or behavioural effects (e.g. psychomotor
hyperactivity, sleep disorders, anxiety, depression, and aggression). More recently,
ICS have been associated with a dose-related increased risk of both diabetes onset
and diabetes progression; albeit from an observational study with inherent limitations.
The Committee on Safety of Medicines (CSM) has issued warnings about the use of
high dose ICS, particularly in children, and in relation to fluticasone. Children
prescribed ICS should have their growth monitored annually (although isolated
growth failure is not a reliable indicator of adrenal suppression).
The BTS/SIGN guideline recommends that reductions in ICS dose should be
considered every three months, decreasing the dose by approximately 25–50% each
time. Data suggest that this is realistic and possible without compromising patient
care. For some children with milder asthma and a clear seasonal pattern to their
symptoms, a more rapid dose reduction during their ‘good’ season is feasible.The
guideline states that stepping down therapy once asthma is controlled is
recommended, but often not implemented, leaving some patients over-treated.
More information on asthma can be found within the respiratory tract NPC e-learning
materials.
There is currently no prescribing comparator for this topic. However, the development
of a suitable comparator continues to be explored.
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Hypnotics
Options for local implementation
•
Review and, where appropriate, revise prescribing of hypnotics to ensure that it is
in line with national guidance.
Evidence context
Risks associated with long term use of hypnotic drugs have been well recognised for
many years. As long ago as 1988, the Committee on Safety of Medicines advised
that benzodiazepine hypnotics should be used only if insomnia is severe, disabling or
causing the patient extreme distress. The lowest dose that controls symptoms should
be used, for a maximum of four weeks and intermittently if possible. NICE guidance
on zaleplon, zolpidem and zopiclone (the so called ‘Z drugs’) also recommends that
when, after due consideration of the use of non-pharmacological measures, hypnotic
drug therapy is considered appropriate for the management of severe insomnia
interfering with normal daily life, hypnotics should be prescribed for short periods of
time only, in strict accordance with their licensed indications. NICE also confirms that
there is no compelling evidence of a clinically useful difference between the ‘Z drugs’
and shorter-acting benzodiazepine hypnotics from the point of view of their
effectiveness, adverse effects, or potential for dependence or abuse. There is no
evidence to suggest that if patients do not respond to one of these hypnotic drugs,
they are likely to respond to another. The MHRA highlighted again the issues
regarding addiction to benzodiazepines in the July 2011 edition of Drug Safety
Update which points to a structured review by the National Addiction Centre of
available evidence on prescribing trends in benzodiazepines and ‘Z drugs’ and
current evidence for the extent of dependence and harms attributable to these drugs.
Despite these national safety warnings and guidance, overall prescribing of hypnotics
is not decreasing.
Various approaches to reducing hypnotic prescribing can achieve significant
success. See Moving towards personalising medicines management: Improving
outcomes for people through the safe and effective use of medicines. More
information on insomnia can be found within the CNS and mental health NPC elearning materials.
A prescribing comparator is available to support this QIPP topic – ‘Hypnotics
ADQ/STAR PU’: the total number of average daily quantities (ADQs) for
benzodiazepines (indicated for use as hypnotics) and ‘Z drugs’ per STAR-PU.
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Low dose antipsychotics in people with dementia
Options for local implementation
•
Review and, where appropriate, revise prescribing of low dose antipsychotics in
people with dementia, in accordance with NICE/SCIE guidance and the NICE
Quality Standard on dementia.
Evidence context
The harms and limited benefits of using antipsychotic drugs, both first (typical) and
second (atypical) generation, for the treatment of people with dementia who exhibit
challenging behaviours are well recognised. They have been the subject of several
previous reviews and MHRA warnings, collated in MeReC Rapid Review No. 847.
In November 2009, the Banerjee report (reviewed in MeReC Rapid Review No. 847)
suggested that up to a quarter of patients with dementia are prescribed
antipsychotics, of whom only one in five will benefit from the treatment. The report
stated that antipsychotics are too often used as a first-line response to behavioural
difficulty in dementia, rather than as a considered second-line treatment when other
non-pharmacological approaches have failed.
In September 2010, the Department of Health published an implementation plan for
‘Living well with dementia: A National Dementia Strategy’, reviewed in MeReC Rapid
Review number No. 3471. In July 2011, a best practice guide, 'Optimising treatment
and care for people with behavioural and psychological symptoms of dementia', was
produced by the Alzheimer’s Society, endorsed by the Department of Health. These
resources build on the NICE/SCIE guideline for the management of people with
dementia who develop behavioural and psychological symptoms, and include
strategies to reduce inappropriate prescribing of antipsychotics.
Underlying health problems, such as pain, should be considered as one of the
potential causes of behavioural problems in people with dementia and should be
managed appropriately. A trial of an analgesic (such as paracetamol) to control pain
is recommended in the best practice guide, where other specific interventions have
been unsuccessful and symptoms are causing extreme distress or risk. This
approach to the management of behavioural symptoms in dementia is discussed in
MeReC Rapid Review No. 4119.
In October 2011, the NHS Institute for Innovation and Improvement published an
economic evaluation of alternatives to antipsychotic drugs for individuals living with
dementia in England. It estimated that using behavioural interventions to treat
behavioural and psychological symptoms in people with dementia, rather than
antipsychotics, would cost an extra £27.6 million per year, but yield health care
savings of nearly £70.4 million (due to the reduced incidence of stroke and falls). The
net benefit of behavioural interventions (combining cost savings and quality of life
improvements) was estimated at nearly £54.9 million per year.
Prescribers should continue to follow the NICE/SCIE guideline for the management
of people with dementia who develop behavioural and psychological symptoms. This
advises avoiding the use of any antipsychotics (first and second generation) for non15 of 32
cognitive symptoms or challenging behaviour of dementia unless the patient is
severely distressed or there is an immediate risk of harm to them or others. Any use
of antipsychotics should include a full discussion with the patient and/or carers about
the possible benefits and risks of treatment.
More information on the prescribing of antipsychotics can be found within the
dementia NPC e-learning materials.
There is currently no prescribing comparator for this topic. However, the development
of a suitable comparator continues to be explored.
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First-choice antidepressant use in adults with depression or
generalised anxiety disorder
Options for local implementation
•
Review and, where appropriate, revise prescribing of antidepressants in adults to
ensure that it is in line with NICE guidance.
Evidence context
The use of antidepressants in adults with depression or generalised anxiety disorder
(GAD) has been addressed by several NICE guidelines. NICE guidelines cover
depression in adults, depression in adults with chronic physical health problems and
anxiety (GAD and panic disorder in adults). The NICE guideline on common mental
health disorders brings these recommendations together, and can be used to help
clinicians, commissioners and managers develop effective local care pathways for
such patients.
NICE advocates a stepwise approach to the management of common mental health
disorders, offering or referring for the least intrusive, most effective intervention first.
Therefore, for many people with depression or GAD, non-drug interventions (such as
cognitive behavioural therapy [CBT]) should be the mainstay of treatment, with drugs
generally being reserved for more severe illness or when symptoms have failed to
respond to non-drug interventions.
The Improving Access to Psychological Therapies programme (www.iapt.nhs.uk)
was introduced by the Department of Health in October 2007, and has improved
primary care access to psychological therapy for the management of depression and
anxiety disorders in England. Despite this, prescribing figures from primary care in
England suggest that antidepressant prescribing is still increasing. In view of NICE
guidance, it would seem advisable to review local antidepressant prescribing and
consider this alongside the local availability of non-drug treatments, such as CBT.
Where an antidepressant is indicated for a patient with depression, NICE
recommends that it should normally be a selective serotonin reuptake inhibitor
(SSRI) in generic form. SSRIs are equally as effective as other antidepressants and
have a favourable risk benefit ratio. Similarly, where drug treatment is indicated for
GAD, and a person chooses to take medication, NICE recommends offering them an
SSRI. Consideration should be given to offering sertraline first for GAD because it is
the most cost-effective drug in this condition (noting that it does not currently have a
UK marketing authorisation for GAD).
The full NICE guideline on depression in adults concluded that antidepressants have
largely equal efficacy and that choice should largely depend on side-effect profile,
patient preference and previous experience of treatments, propensity to cause
discontinuation symptoms, safety in overdose, interactions and cost. However, a
generic SSRI is recommended as first-choice because of their favourable risk-benefit
ratio. Neither escitalopram, nor any of the available ‘dual action’ antidepressants,
such as venlafaxine and duloxetine, were judged to confer any clinically important
advantages over other antidepressants. Indeed, when NICE considered the findings
from a multiple-treatments meta-analysis by Cipriani et al (see MeReC Rapid Review
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No. 283) and developed an economic model based on the data, they concluded that
the findings were not sufficiently robust to warrant singling out individual drugs for
recommendation. Results from a further recent meta-analysis provide no reason to
depart from NICE guidance when selecting antidepressants for patients with
depression.
The full NICE guideline on GAD and panic disorder found that of the antidepressants
available, there was sufficient clinical effectiveness data and an acceptable harm-tobenefit ratio for escitalopram, duloxetine, paroxetine, sertraline and venlafaxine XL.
However, the economic analysis concluded that sertraline was the most costeffective drug in the treatment of people with GAD, as it was associated with the
highest number of QALYs and the lowest total costs among all treatments assessed,
including no treatment. As with depression, drug choice in GAD should also be
influenced by several other factors relating to the individual patient, including their
previous experience of treatments, likely drug interactions, safety and tolerability.
Drug safety warnings on antidepressants that have been issued by the MHRA should
be considered. See the December 2011 edition of Drug Safety Update and MeReC
Rapid Review No. 4765 for details about the association of dose-dependent QT
interval prolongation with citalopram and escitalopram.
Prescribing figures from primary care in England show that SSRIs remain
consistently the most commonly prescribed group of antidepressants. However, all
other antidepressants (including tricyclic antidepressants) still account for nearly half
of total prescribing.
More information on the use of antidepressants can be found within the depression
and anxiety NPC e-learning materials. See also specific NICE guidance for the use of
antidepressants in antenatal and post natal mental health, and in children and young
people.
A prescribing comparator is available to support this QIPP topic –
‘Antidepressants: ADQ/STAR-PU’: the total number of average daily quantities
(ADQs) of all antidepressant prescribing (BNF 4.3) per STAR-PU.
18 of 32
Antibiotic prescribing – especially quinolones and
cephalosporins
Options for local implementation
•
•
•
Review and, where appropriate, revise current prescribing practice and use
implementation techniques to ensure prescribing is in line with Health Protection
Agency (HPA) guidance.
Review the total volume of antibiotic prescribing against local and national data.
Review quinolone and cephalosporin prescribing against local and national data.
Evidence context
Antibiotic resistance poses a significant threat to public health and new infectious
diseases and pathogens are continually being identified. Emerging resistance against
antimicrobials that are currently used, and the upsurge in a number of types of
infections, some of which had previously been well-controlled, are two factors that
contribute to this threat.
Of particular concern is methicillin-resistant Staphylococcus aureus (MRSA) which
remains a serious threat, especially to hospital inpatients. Addressing healthcareassociated Clostridium difficile infection also remains a key issue on which NHS
organisations have been mandated to implement national guidance that includes
restriction of broad spectrum antibiotics, and in particular second and thirdgeneration cephalosporins and clindamycin. Broad spectrum antibiotics, such as
quinolones and cephalosporins, need to be reserved to treat resistant disease, and
should generally be used only when standard and less expensive antibiotics are
ineffective. See Clostridium difficile infection: How to deal with the problem.
The prescribing of quinolones (e.g. ciprofloxacin) in general practice is a particular
cause for concern. They are recommended first-line by the HPA only in limited
situations (e.g. acute pyelonephritis or acute prostatitis). Resistance to quinolones is
increasing at a considerable rate e.g. quinolone resistant Neisseria gonorrhoeae
(QRNG), in which resistance is usually high-level and affects all the quinolones. See
Susceptibility testing of N. gonorrhoeae.
More information on antibiotic prescribing can be found within the common infections
NPC e-learning materials.
Two prescribing comparators are available to support this QIPP topic. The titles of
these are:
1. ‘Antibacterial items/STAR-PU’: the number of prescription items for
antibacterial drugs (BNF 5.1) per STAR-PU.
2. ‘Cephalosporins and quinolones % items’: the number of prescription items for
cephalosporins and quinolones as a percentage of the total number of
prescription items for selected antibacterial drugs (BNF 5.1).
19 of 32
Three-day courses of trimethoprim for uncomplicated urinary
tract infection
Options for local implementation
•
Review and, where appropriate, revise current prescribing practice and use
implementation techniques to ensure prescribing of three-day courses of
trimethoprim is in line with Health Protection Agency (HPA) guidance.
Evidence context
According to HPA guidance, a three-day course of antibiotic is sufficient for acute
symptomatic uncomplicated urinary tract infection (UTI) in non-pregnant women.
Uncomplicated UTI has been defined as infection in a person with a normal urinary
tract and normal renal function. Trimethoprim (200 mg twice daily) is an effective firstline treatment. Nitrofurantoin (100 mg modified release twice daily) is also suitable,
but is currently more expensive.
Culture and sensitivity testing should be performed if first-line treatment fails. As
discussed in a MeReC Bulletin from December 2006, although rates of resistance to
trimethoprim have been reported to be high (20–40%), it should be remembered that
resistance rates are based on urine samples from hospitals and from primary care
which are likely to disproportionately represent more complicated cases and
treatment failures, with fewer samples collected from women with uncomplicated UTI.
Amoxicillin resistance is common and it should be used only if culture and sensitivity
testing proves the organism is susceptible. Broad spectrum antibiotics (e.g. coamoxiclav, quinolones and cephalosporins) should be avoided where possible
because they increase risk of Clostridium difficile, MRSA and resistant UTIs.
A Cochrane review supports the use of three-day courses of antibiotic therapy for
uncomplicated UTI. Symptomatic failure rate was assessed and, at both short- and
long-term follow-up, no significant difference was found in the number of patients
who still had symptoms following three-day, or five- to ten-day, antibiotic treatment,
but shorter courses were associated with a 17% reduction in side effects. The review
concluded that three days of antibiotic therapy is similar to five to ten days in
achieving symptomatic cure in non-pregnant women aged 18–65 years old. Longer
treatment was more effective than three-day treatment to achieve bacteriological
cure. Therefore, longer courses may be considered in complicated UTI (e.g.
pyelonephritis, pregnancy, recurrent UTI) where eradication of bacteriuria is
important.
More information on managing uncomplicated UTIs can be found in the MeReC
Bulletin: Management of common infections in primary care and in the Common
infections – UTI e-learning materials on the NPC website.
A prescribing comparator is available to support this QIPP topic – ‘3 days
trimethoprim ADQ/item’: the total number of average daily quantities (ADQs) per
item for trimethoprim 200 mg tablets.
20 of 32
Minocycline
Options for local implementation
•
Review and, where appropriate, revise prescribing of minocycline in light of its
potential harms.
Evidence context
Although minocycline has various indications, it is used primarily as one of a number
of oral antibiotics available for the treatment of acne. Unlike some other drugs in its
class e.g. tetracycline and oxytetracycline, it is available as a once-daily treatment
and need not be taken on an empty stomach. However, there are concerns regarding
its place in therapy:
•
•
•
•
There is no clear evidence that minocycline is more effective or better tolerated
than other tetracyclines.
There are safety concerns specific to minocycline (see below).
Alternative once-daily treatments e.g. doxycycline and lymecycline are available.
Minocycline has a relatively high acquisition cost.
A Cochrane review from 2003 found minocycline may be associated with a broader
spectrum and higher incidence of adverse drug reactions than other tetracyclines
including:
• single organ dysfunction (including potentially fatal liver failure)
• autoimmune disorders (such as lupus-like syndrome, the risk of which increases
with cumulative dose)
• hypersensitivity reactions (including eosinophilia, pneumonitis, and nephritis).
The Cochrane review found no evidence to justify the use of minocycline first-line in
acne, given its cost and concerns over safety. Furthermore, a systematic review
published in 2008, which assessed the relative effectiveness of oral tetracyclines in
inflammatory acne, concluded that there was insufficient evidence to support one
tetracycline over another in terms of efficacy.
A 2006 Drug and Therapeutics Bulletin which reviewed the available evidence found
no convincing evidence to support the preference of minocycline over other
tetracyclines in acne when its association with serious unwanted effects is taken into
account. In a 2009 update, they stated ‘We cannot see a place for minocycline in the
management of patients with acne.’
As well as important quality issues, of the recommended treatments in acne,
minocycline remains one of the more costly oral options. The savings of substituting
minocycline for an alternative tetracycline have been estimated to be approximately
£2.2 million.
The national median prescribing rate by PCT for minocycline as a percentage of
tetracyclines is 5%. However, the variation between PCTs is marked, ranging from
1.79% to 19.6%, and there may be wider variation still at practice level.
21 of 32
A prescribing comparator is available to support this QIPP topic – ‘Minocycline
ADQ/STAR-PU’: the total number of average daily quantities (ADQs) for minocycline
prescribed per STAR-PU.
22 of 32
Type 2 diabetes mellitus
Options for local implementation
•
•
•
In type 2 diabetes mellitus consider carefully the risks and benefits of both
intensive glycaemic control and use of hypoglycaemic agents. Review and,
where appropriate, revise prescribing to ensure that it is in line with NICE
guidance.
Review and, where appropriate, revise prescribing of long-acting insulin
analogues in type 2 diabetes mellitus to ensure that it is in line with NICE
guidance.
Review and, where appropriate, revise local use of self-monitoring of blood
glucose (SMBG) in type 2 diabetes mellitus to ensure that it is in line with NICE
guidance.
Evidence context
The management of patients with type 2 diabetes is complex, requiring an
individualised multifactorial approach. Controlling blood glucose requires a careful
balance. There are no arguments in favour of poor glucose control. However,
achieving good blood glucose control, while addressing blood pressure, blood lipids,
and lifestyle issues (smoking cessation, exercise, losing weight, healthy diet etc.)
seems likely to prevent more complications, than a narrower approach focused on
intensive blood glucose control.
NICE guidance on type 2 diabetes recommends that patients should be involved in
setting their individualised HbA1c target level, which may be above the general
target of 48 mmol/mol (6.5%). Any reduction in HbA1c towards the agreed target
level is advantageous to future health, but pursuing highly intensive management to
HbA1c levels below 48 mmol/mol (6.5%) should be avoided.
The Quality and Outcomes Framework (QOF) allocates points for achieving three
levels of glucose control in patients with type 2 diabetes — HbA1c of 59 mmol/mol
(7.5%) or less, 64 mmol/mol (8%) or less, and 75 mmol/mol (9%) or less. If
appropriate and achievable in an individual, reducing blood glucose to HbA1c levels
of around 59 mmol/mol (7.5%) would seem optimal based on current evidence.
Lower levels may be appropriate in individuals with early disease, or if these levels
can be achieved reasonably easily with diet or metformin alone.
Intensive versus conventional blood glucose control
The CONTROL meta-analysis of the four key RCTs suggests a small absolute
benefit of intensive compared with conventional blood glucose control in people with
type 2 diabetes in reducing coronary heart disease (but not stroke, death from
cardiovascular disease or death from all causes) – see MeReC Rapid Review No.
2726. Other meta-analyses have made similar findings in relation to macrovascular
outcomes (MeReC Rapid Reviews No. 4416, 435 and 351). However, an emerging
body of evidence suggests the benefit is not as great as that achieved by blood
pressure control or lipid lowering.
There appears to be a reduction in certain microvascular events with intensive
compared with conventional blood glucose control. However, results of meta23 of 32
analyses are inconsistent, and some endpoints were disease oriented outcomes, e.g.
microalbuminuria. Any possible microvascular benefits need to be balanced against
the significantly increased risk of severe hypoglycaemia with intensive blood glucose
control. Reducing blood glucose levels intensively may actually be harmful – see
MeReC Rapid Review No. 1017.
A recent randomised controlled trial (RCT) found no significant benefits for early
detection and intensive multifactorial management of type 2 diabetes in improving
any patient-oriented cardiovascular outcomes over five years, compared with usual
care – see MeReC Rapid Review No. 4233.
Role of newer hypoglycaemic drugs
Treatment to control blood glucose must be tailored to each individual patient's
clinical needs with safety paramount. It is generally agreed, and supported by the
NICE guideline on type 2 diabetes, that metformin should be used first line and a
sulfonylurea second line, unless contraindicated. The newer hypoglycaemic drugs
are all usually third-line options.
Although newer hypoglycaemic drugs are effective at reducing HbA1c levels, they all
lack robust clinical outcome data, particularly around their cardiovascular effects and
long term safety in people with type 2 diabetes. Improvements in surrogate markers
(e.g. HbA1c levels) do not automatically confer benefits on patient mortality or
morbidity, and risks may become apparent only over time when these agents have
more widespread use in a diverse patient population.
Rosiglitazone was withdrawn from clinical use in September 2010 due to increased
cardiovascular risks. The MHRA has highlighted several safety concerns with
pioglitazone, which have been incorporated into the summary of product
characteristics (SPC). The SPC includes the following:
– Pioglitazone is contraindicated in patients with heart failure or a history of heart
failure. Patients should be observed for signs and symptoms of heart failure,
weight gain or oedema; particularly those with reduced cardiac reserve and when
pioglitazone is used in combination with insulin. Pioglitazone should be
discontinued if any deterioration in cardiac status occurs.
– Pioglitazone is contraindicated in patients with bladder cancer or a history of
bladder cancer, or in patients with uninvestigated macroscopic haematuria. Risk
factors for bladder cancer (age, smoking history, exposure to some occupational
or chemotherapy agents or prior radiation treatment in the pelvic region) should
be assessed before initiating pioglitazone, and any macroscopic haematuria
investigated.
– In light of age-related risks (especially bladder cancer, fractures and heart
failure), the balance of benefits and risks should be considered carefully both
before and during treatment with pioglitazone in the elderly.
– After initiation of pioglitazone, patients should be reviewed after three to six
months to assess adequacy of response to treatment (e.g. reduction in HbA1c).
In patients who fail to show an adequate response, pioglitazone should be
discontinued. In light of potential risks with prolonged therapy, prescribers should
confirm at subsequent routine reviews that the benefit of pioglitazone is
maintained.
Current NICE guidance states that pioglitazone, sitagliptin or vildagliptin (saxagliptin
was not licensed at the time of the NICE review) can be considered for dual therapy
with either metformin or a sulfonylurea when either of these latter drugs is
24 of 32
contraindicated, not tolerated or (in the case of sulfonylureas) there is a significant
risk of hypoglycaemia. Pioglitazone and sitagliptin can also be considered for triple
therapy with metformin and a sulfonylurea if insulin is unacceptable or inappropriate.
NICE recommends that pioglitazone or the gliptins should be continued only if the
person shows a reduction in HbA1c of at least 5.5 mmol/mol (0.5%) at six months.
NICE recommends that exenatide (in clinical guideline 87), liraglutide (in technology
appraisal 203) or exenatide prolonged-release (in technology appraisal 248) can be
considered for triple therapy with metformin and a sulfonylurea (or metformin and
pioglitazone for liraglutide or exenatide prolonged-release) if specific criteria are met.
Liraglutide and exenatide prolonged-release can also be a dual therapy option, but
only in very limited circumstances in people who are unable to take metformin or a
sulfonylurea and are unable to take pioglitazone and are unable to take a gliptin.
Again, these newer agents should be continued only if there is a beneficial metabolic
response; defined in the case of exenatide, liraglutide and exenatide prolongedrelease as a reduction in HbA1c of at least one percentage point (11mmol/mol) and a
weight loss of at least 3% of initial body weight, at six months. The need for
parenteral administration of exenatide or liraglutide may be regarded as a
disadvantage by patients. Potential safety issues including severe pancreatitis and
renal failure have also been highlighted by the MHRA with regard to exenatide.
Role of long-acting insulin analogues
The NICE guideline on type 2 diabetes recommends that, when insulin therapy is
necessary, human NPH (isophane) insulin (e.g. Insulatard®, Humulin I® or
Insuman® Basal) is the preferred option. Long-acting insulin analogues have a role
in some patients, and can be considered for those who fall into specific categories
e.g. those who require assistance from a carer or healthcare professional to
administer their insulin injections, or those with problematic hypoglycaemia.
However, for most people with type 2 diabetes, long-acting insulin analogues offer no
significant advantage over human NPH insulin and are much more expensive.
A health economic analysis by NICE found that the cost effectiveness of long-acting
insulin analogues was not favourable. The incremental cost-effectiveness ratio
per QALY (compared with conventional insulin) was greater than £100,000 in
all scenarios, and in some scenarios in excess of £400,000. Importantly, this
analysis incorporated the anticipated health-related quality of life gain associated with
the reduced fear of severe hypoglycaemic episodes (see MeReC Rapid Review No.
826). These costs are substantially greater than the £20,000 to £30,000 per QALY
threshold usually considered in NICE’s cost-effectiveness evaluation. The results of a
Canadian Heath Technology Assessment are also consistent with the health
economic analysis conducted by NICE for long-acting insulin analogues in type 2
diabetes. See MeReC Rapid Review No. 318. Nevertheless, the prescribing of these
agents has increased enormously over the past few years.
A prescribing comparator to support this QIPP topic (see below) shows that, in the
majority of PCTs, more than 80% of all intermediate or long-acting insulin items
(excluding biphasic insulins) are now for the long-acting insulin analogues, insulin
glargine or insulin detemir, and in many PCTs the proportion is more than 90%.
People with glycaemic control problems should be properly assessed for underlying
causes before these newer, more expensive insulins are considered. This includes
education and checking understanding around how to manage their disease and
treatment. Any decision to start a long-acting insulin analogue needs to be balanced
25 of 32
carefully against the limited long-term safety and outcome data there are for these
agents and their high prescribing costs.
Role of self-monitoring of blood glucose (SMBG)
The NICE guideline on type 2 diabetes gives recommendations on the place of
SMBG in people with type 2 diabetes. NICE recommend it should be used only if it is
going to be an integral part of the patients’ self-management education, and the
continued benefit of self-monitoring should be assessed in a structured way each
year. It should be offered to patients on insulin and sulfonylureas as they are at risk
of hypoglycaemia.
A recent Cochrane review found the overall effect of SMBG on glycaemic control in
patients with type 2 diabetes who were not using insulin was small up to six months
after initiation, and subsides after 12 months. There was no evidence that SMBG
affects patient satisfaction, general well-being or general health-related quality of life.
Health professionals should also be aware of DVLA recommendations on the
monitoring of blood glucose, in order to best advise patients about their own
particular requirements. See MeReC Rapid Review No. 4937.
More information on type 2 diabetes can be found within the type 2 diabetes NPC elearning materials and in MeReC Bulletins from June 2011 and March 2012. For
detailed guidance on SMBG see ‘Self-monitoring of blood glucose in non-insulintreated type 2 diabetes’ published by NHS Diabetes.
Two prescribing comparators are currently available to support this QIPP topic, while
a further two are under development. The titles of the current comparators are:
1. ‘Hypoglycaemic drugs’: the number of prescription items for metformin and
sulfonylureas as a percentage of the total number of prescription items for all
antidiabetic drugs.
2. ‘Long/intermediate insulin analogues’: the number of prescription items for
long acting human analogue insulins detemir and glargine as a percentage of the
total number of prescription items for all long acting and intermediate acting
insulins excluding biphasic insulins.
The two comparators under development will utilise information from the GP Quality
and Outcomes Framework, such as QOF patient registers.
26 of 32
Non-steroidal anti-inflammatory drugs (NSAIDs)
Options for local implementation
•
•
•
•
•
•
Review the appropriateness of NSAID prescribing widely and on a routine basis,
especially in people who are at higher risk of both gastrointestinal (GI) and
cardiovascular (CV) morbidity and mortality (e.g. older patients).
If initiating an NSAID is obligatory, use ibuprofen (1200 mg per day or less) or
naproxen (1000 mg per day or less).
Review patients currently prescribed NSAIDs. If continued use is necessary,
consider changing to ibuprofen (1200 mg per day or less) or naproxen (1000 mg
per day or less).
Review and, where appropriate, revise prescribing of etoricoxib to ensure it is in
line with MHRA advice and the NICE clinical guideline on osteoarthritis.
Co-prescribe a proton pump inhibitor (PPI) with NSAIDs for people with
osteoarthritis, rheumatoid arthritis, or low back pain (for people over 45 years) in
accordance with NICE guidance.
Take account of drug interactions when co-prescribing NSAIDs with other
medicines (see Summaries of Product Characteristics). For example, coprescribing NSAIDs with ACE inhibitors or angiotensin receptor blockers (ARBs)
may pose particular risks to renal function; this combination should be especially
carefully considered and regularly monitored if continued.
Evidence context
There are long standing and well recognised safety concerns with all NSAIDs
regarding GI and renal adverse effects, and increased risk of CV events with many
NSAIDs, including coxibs and some traditional NSAIDs. The lowest effective dose of
NSAID should be prescribed for the shortest time necessary for control of symptoms.
In October 2006, a review of the CV safety of selective and non-selective NSAIDs by
the Commission on Human Medicines (CHM) identified that traditional NSAIDs,
including diclofenac, may be associated with a small increased risk of arterial
thrombotic events. This risk does not appear to be shared by ibuprofen at 1200 mg
per day or less, or naproxen 1000 mg per day. Subsequently published data (see
MeReC Rapid Reviews No. 1597, 2451 and 4481) support these recommendations,
particularly for naproxen. A cohort study of patients who had suffered a myocardial
infarction (MI) suggests that even short-term use of NSAIDs (some for as little as one
week) is associated an increased risk of death or recurrent MI. Consistent with other
studies, diclofenac was found to have the highest risk, and naproxen the lowest.
There has been a significant shift in the prescribing of diclofenac to naproxen over
the last three years, with a particular shift since around April 2011. However, from
September to November 2011, diclofenac still accounted for approximately 1 million
prescription items (25% of all NSAID items) in primary care in England, and there are
still wide differences between localities with regard to the total proportion of NSAIDs
prescribed which are ibuprofen or naproxen (range 32% to 73%, July to September
2011).
Other safety concerns have also been highlighted with etoricoxib specifically. The
MHRA has advised that etoricoxib may be associated with more frequent and severe
effects on blood pressure than some other coxibs and NSAIDs, particularly at high
27 of 32
doses. Therefore, hypertension should be controlled before treatment with etoricoxib
and special attention should be paid to blood pressure monitoring during treatment
with etoricoxib. Blood pressure should be monitored within two weeks after initiation
of treatment and periodically thereafter. If blood pressure rises significantly,
alternative treatment should be considered. The NICE clinical guideline on
osteoarthritis recommends against using the 60 mg dose first-line on the basis of
cost-effectiveness. The European Medicines Agency’s Committee for Medicinal
Products for Human Use (CHMP) assessed the long-term benefits and risks of
etoricoxib in patients with rheumatoid arthritis or ankylosing spondylitis and
concluded that the benefits outweighed the risks in these conditions, when used at a
dose of 90 mg daily.
More information on NSAIDs can be found within the musculoskeletal pain NPC elearning materials.
Two prescribing comparators are available to support this QIPP topic. The titles of
these are:
1. ‘NSAIDs: Ibuprofen & naproxen % items’: the total number of ibuprofen and
naproxen items prescribed as a proportion of the total number of all NSAID items.
2. ‘NSAIDs: ADQ/STAR-PU’: the total number of average daily quantities (ADQs)
of all NSAIDs prescribed per STAR-PU.
28 of 32
Wound care products
Options for local implementation
•
•
•
Review and, where appropriate, revise prescribing of wound dressings to ensure
that the least costly dressings that meet the required clinical performance
characteristics are routinely chosen.
Prescribe the minimum quantity of dressings sufficient to meet patient
requirements.
Do not routinely choose antimicrobial (e.g. silver, iodine, honey) dressings ahead
of non-medicated dressings.
Evidence context
Choosing wound dressings on the basis of clinical evidence is hindered by the
relative lack of robust clinical or cost-effectiveness evidence, as highlighted in
numerous systematic reviews (see MeReC Bulletin from July 2010 and Cochrane
Reviews). Although there is some evidence that modern/advanced dressings (e.g.
hydrocolloids, alginates, hydrofibre dressings) are more clinically effective than
conventional dressings (e.g. gauze) for treating wounds, there is insufficient evidence
to distinguish between them.
A large number of wound dressings are available with a wide range of physical
performance characteristics (e.g. size, adhesion, conformability, fluid handling
properties). Although laboratory characterisation tests provide a means of comparing
their performance, they cannot always predict how the dressings will perform in the
clinical situation.
Dressing selection should be made following careful clinical assessment of the
patient's wound, their clinical condition, their personal experience and preferences. In
the absence of any robust clinical evidence to guide choice, prescribers should
choose routinely the dressing having the lowest acquisition cost with the
performance characteristics appropriate for the wound and its stage of healing.
There is at present no robust clinical or cost-effectiveness evidence to support the
use of antimicrobial dressings (e.g. silver, iodine, honey) ahead of non-medicated
dressings for the prevention or treatment of chronic wounds. Indiscriminate use
should be discouraged because of concerns over bacterial resistance and toxicity.
Antimicrobial dressings may be considered to help reduce bacterial numbers in
wounds, but should be avoided unless the wound is infected or there is a clinical risk
of them becoming infected. According to the BNF, dressings containing silver should
only be used when infection is suspected as a result of clinical signs and symptoms.
They should not be used on acute wounds (as there is some evidence that they
delay healing) or routinely for the management of uncomplicated ulcers. Antimicrobial
dressings should be prescribed for defined short-periods of time and their use
reviewed regularly.
Wound care products are sometimes prescribed in large quantities to patients for use
on an as-needed basis. An audit of wound care dressings in one community locality
in the West Midlands* found that unused dressings accounted for about 35% of the
volume of wound dressings prescribed. A local medicines management focus on
29 of 32
wound care, including a local formulary, can result in improved wound care
management, waste reduction and cost savings (e.g. see Northumberland Care Trust
case study).
The minimum quantity of dressings necessary to meet patient needs should be
prescribed to avoid wastage. Healthcare professionals making visits to patients with
chronic wounds should monitor supplies to prevent stockpiling.
Further information on the prescribing of dressings for chronic wounds in primary
care can be found in the MeReC Bulletin from July 2010.
There is currently no prescribing comparator for this topic. However, the development
of a suitable comparator is being explored.
*Personal communication
30 of 32
Section 2
QIPP PRESCRIBING COMPARATORS
A set of 14 comparators are currently available to support the QIPP (Quality,
Innovation, Productivity and Prevention) medicine use and procurement workstream.
This includes some revisions, additions and deletions from the QIPP Prescribing
Comparators previously available.
The comparators cover 10 of the 13 therapeutic areas covered in this document.
The aim of the comparators is to allow organisations and prescribers to review the
appropriateness of current prescribing, revise prescribing where appropriate and
monitor implementation. The comparators are not intended to be used as targets or
performance tables but rather highlight variation and support local discussion and
decisions regarding QIPP. For a number of topics more detailed work, probably
involving patient-level audit, may be required to understand whether current practice
–as identified in the comparator– is based on implementation of recommended
practice or not, and the need for this applies whether the current prescribing is ‘low’,
‘high’ or ‘average’ and to all topics.
A set of charts and data tables showing values for all PCTs is available on the NHS
Prescription Services (NHS RxS) website. Individual PCTs can be highlighted by
selecting the PCT from the drop down menu in each chart. PCTs are also able to
view comparator values at practice level via the NHSBSA Prescription Services
Prescribing Toolkit.
NPC Key
Therapeutic
Topic
Toolkit QIPP comparator
Laxatives
Total items for laxatives per 1000 Astro-PUs.
Renin-angiotensin
system drugs
Number of prescription items for angiotensin converting enzyme
(ACE) inhibitors as a percentage of the total number of prescription
items for all drugs affecting the renin-angiotensin system excluding
aliskiren.
Lipid modifying
drugs including
ezetimibe
Number of prescription items for simvastatin and pravastatin as a
percentage of the total number of prescription items for all statins,
plus the total number of prescription items for combination of
simvastatin/ezetimibe, plus the total number of prescription items for
ezetimibe alone.
Number of items for ezetimibe and ezetimibe/simvastatin
combinations as a percentage of the total number of prescription
items for all statins, plus the total number of prescription items for
combination of simvastatin/ezetimibe, plus the total number of
prescription items for ezetimibe alone.
31 of 32
Hypnotics
Total number of average daily quantities (ADQs) for
benzodiazepines (indicated for use as hypnotics) and ’Z drugs’ per
Star-PU.
First-choice
antidepressant use
in adults with
depression or
generalised anxiety
disorder
Antibiotic prescribing
– especially
quinolones and
cephalosporins
Total number of average daily quantities (ADQs) for all
antidepressant prescribing (BNF 4.3) per Star-PU.
Three-day courses
of trimethoprim for
uncomplicated
urinary tract infection
Minocycline
Total number of average daily quantities (ADQs) per item for
trimethoprim 200mg tablets.
Type 2 diabetes
mellitus
Number of prescription items for metformin and sulfonylureas as a
percentage of the total number of prescription items for all
antidiabetic drugs.
Number of prescription items for antibacterial drugs (BNF 5.1) per
Star-PU.
Number of prescription items for cephalosporins and quinolones as a
percentage of the total number of prescription items for selected
antibacterial drugs (BNF 5.1).
Total number of average daily quantities (ADQs) for minocycline per
Star-PU.
Number of prescription items for long acting human analogue
insulins detemir and glargine as a percentage of the total number of
prescription items for all long acting and intermediate acting insulins
excluding biphasic insulins.
Non-steroidal antiinflammatory drugs
(NSAIDs)
Number of prescription items for ibuprofen and naproxen as a
percentage of the total number of prescription items for all NSAIDs.
Number of average daily quantities (ADQs) for all NSAIDs (BNF
10.1.1) per Star-PU.
Full descriptions and specifications for the QIPP comparators are available on the
Health and Social Care Information Centre website.
‘The National Prescribing Centre (NPC) is responsible for helping the NHS to optimise its use of
medicines. NPC is part of the National Institute for Health and Clinical Excellence (NICE), an
independent organisation providing national guidance on promoting good health and preventing and
treating ill health.
© National Institute for Health and Clinical Excellence, 2012. All rights reserved. This material may be
freely reproduced for educational and not-for-profit purposes. No reproduction by or for commercial
organisations, or for commercial purposes, is allowed without the express written permission of NICE.’
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