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

Linda Renfrew
MS 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

50
45
40
35
30
25
20
15
10
5
0
MS clinic Physio Dom visit Total
Total SP
5
4
3
2
1
0
Numbers of
patients
Muscle
relaxants
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 attendsP pth aytsteion,d ass psehsysseiod & & n neeeeddss t oto s statarrt ts sppaasstctiictyit ym meeddiciacatiotionn
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, pregabalin
etc
 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,PEG
fed, 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)

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

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

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