Application for Endorsement of CQI (Clinical Audit) Activities for MOPS Credits Allocation Below is the form you need to fill out. NAME Dianne Vicary Health Hawke s Bay DATE JUNE 2012 TITLE OF ACTIVITY CLINICAL AUDIT TO PROMOTE NORTRIPTYLINE IN PREFERENCE TO AMITRIPTYLINE IN OLDER PEOPLE NEW APPLICATION GENERAL PRACTITIONERS INVOLVED IN ACTIVITY THIS ACTIVITY WILL BE AVAILABLE TO ALL HEALTH HAWKE S BAY PRESCRIBERS. 1. TOPIC In Hawke s Bay amitriptyline (or other Tricyclic Antidepressants (TCAs)) are prescribed to patients aged 75 years or over, more frequently than nortriptyline. According to the bpac NZ Best Practice Journal Falls report; there were 1009 pharmaceutical claims made between 1 March and 31 August 2009, to patients aged 75 years and older for a TCA; only 23% were for nortriptyline. 1 In the May 2012 bpac NZ Reminders Report, nortriptyline was 30% of all TCA prescriptions in patients aged 75 years or older in 2011; a rise from 25% in 2010. 2 Inappropriate prescribing and polypharmacy are strong risk factors for falls in the elderly; they are also modifiable. 3 Medicines associated with a high risk of falls include antidepressants, antipsychotics, sedatives / hypnotics, and opioid analgesics. 3 Tricyclic antidepressants are commonly used in the treatment of depression and neuropathic pain. If a TCA is indicated, nortriptyline, compared to other TCAs, is preferred in older people due to reduced adverse effects. Nortriptyline is associated with less hypotension, less sedation and less anticholinergic effects (dry mouth, constipation, blurred vision, urinary retention, confusion). 2 2. PLAN This section should be based on the best evidence available, e.g. evidence-based guidelines. INDICATORS (what element of practice performance are you going to measure?) The CQI activity will identify those patient s Aged 75 years and older, who are currently prescribed amitriptyline Patients must be enrolled and registered with the Practice. Patients must be aged 75 years or older at the time the audit is generated. An amitriptyline prescription will have been generated within the past 6 months. RNZCGP MOPS Programme 2011-2013 1
Application for Endorsement of CQI (Clinical Audit) Activities for MOPS Credits Allocation CRITERIA (How will you measure if you are meeting the indicator?) This audit will identify patient s currently prescribed amitriptyline, using either a DrInfo audit tool or by running a query through the patient management system (PMS). The following will be measured: Number of patients prescribed amitriptyline that have a READ code entered for its indication. Number of patients prescribed amitriptyline, for neuropathic pain, with documented consideration of, or changed to, nortriptyline. STANDARDS (what standards of performance do you want to achieve?) Standard Cycle 1: At least 80% of patients (from 20 chosen) prescribed amitriptyline have a READ code entered for its indication. At least 80% of patients (from 20 chosen) prescribed amitriptyline, for neuropathic pain, have it documented that nortriptyline has been considered, or prescribed to replace amitriptyline. Standard Cycle 2: 100% of patients prescribed amitriptyline have a READ code entered for its indication. 100% of patients prescribed amitriptyline, for neuropathic pain, have documentation regarding consideration of, or changed to, nortriptyline. Describe the process used to develop the indicators and criteria above. List guidelines and other resources used. bpac NZ have provided prescribers individualised reports comparing the use of nortriptyline or amitriptyline (or other TCAs) in older people on a number of occasions during the past 3 years, and this has been augmented by Pharmacist Facilitator discussions. TCAs are prescribed for the treatment of depression and neuropathic pain. 4,5 Nortriptyline is termed a secondary amine TCA with noradrenergic activities; while amitriptyline is a tertiary amine with balanced serotonergic and noradrenergic activity. 6,7 The Neuropathic Pain Special Interest Group (NeuPSIG) of the International Association for the Study of Pain (IASP) recommends secondary amine TCAs e.g. nortriptyline as first-line treatment for neuropathic pain and tertiary amines (amitriptyline and imipramine) if a secondary amine is not available. 8 The secondary amines are typically better tolerated with similar efficacy. 8 Both nortriptyline (NNT=1.2, 95% CI, 50% pain relief, 30mg dose) and amitriptyline (NNT=2.1, 95% CI, 50% pain relief, average 90mg dose) have demonstrated efficacy for the treatment of neuropathy. 7 In comparison to amitriptyline, nortriptyline has less anticholinergic effects, sedation, and cardiac abnormalities; limited orthostatic hypotension and weight gain; and no GI distress. 6 TCAs are also associated with falls and fractures. The risk of falls increases with daily dose increase; a rate ratio of 2.4 (95% CI: 2.1 2.8) for doses of 50mg or more of amitriptyline or its equivalent. 9 Nortriptyline is more potent than amitriptyline; therefore when converting from amitriptyline to nortriptyline, it is recommended that the dose is reduced by half, and titration of dose of effect. 1 3. DATA Describe data (to be) collected. Patient selection: A patient list will be generated, according to criteria outlined above, using either a DrInfo audit tool or by running a query through the patient management system (PMS). Sample size and type: Twenty patients prescribed amitriptyline (for indication other than depression). Data record template for Cycle 1 and Cycle 2: Appendix 1 Review process: Appendix 2. Method for identification of patients: Consider entering in a Patient Alert or Patient Task into the patient management software, to alert you to discuss and review use of amitriptyline at the patient s next appointment. RNZCGP MOPS Programme 2011-2013 Health Hawke s Bay Amitriptyline vs Nortriptyline Application June 2012 2
Application for Endorsement of CQI Activities for MOPS Points Allocation When is a second cycle planned? (This includes repeating data, check, act and monitor stages.) It is recommended that a second audit cycle be completed in order to quantify progress. A second audit should be completed within 12 months of completing the first cycle. Practitioners or practices that achieved Standard 1 in the first audit cycle, should aim for Standard 2 in the second audit cycle. COMMENTS This audit is a continuation of messages provided to prescribers by bpac NZ and Health Hawke s Bay pharmacist facilitators. In Hawke s Bay nortriptyline is currently 30% of all tricyclic antidepressants in patients 75 years and older, which is greater than the national average. 9 The aim of this audit is to identify those patients currently on amitriptyline and to initiate further review of the use of this medication in these patients. REFERENCES: 1 bpac NZ BPJ26 Falls. 2010 Hawke s Bay PHO, Tu Meke PHO and Wairoa PHO Reports. 2 bpac NZ Looking back, looking forward: key messages 2007 2011. May 2012 Health Hawke s Bay Report. 3 Rumore MM et al. Development of a Risk Assessment Tool for Falls Prevention in Hospital Inpatients Based on the Medication Appropriateness Index (MAI) and Modified Beer s Criteria. Innovations in Pharmacy. 2010;3(1):article 73. http://www.pharmacy.umn.edu/innovations/prod/groups/cop/@pub/@cop/@innov/documents/article/cop_article_381617. pdf 4 Australian Medicines Handbook 2009 5 Pharmacological management of neuropathic pain. Best Practice Journal 2008; Issue 16. http://www.bpac.org.nz/magazine/2008/september/neuro.asp#two 6 Lacy C et al. Drug Information Handbook 2009-2010. 18 th Edition. Lexi-Comp Inc 7 Sindrup SH et al. Antidepressants in the Treatment of Neuropathic Pain. Basic & Clinical Pharmacology & Toxicology 2005;96:399-409. 8 Kristen Jefferies. Treatment of Neuropathic Pain. Semin Neurol. 2010[Internet];30(4):425-432. Available online: http://www.medscape.com/viewarticle/730671 9 Thapa PB et al. Antidepressants and the risk of falls among nursing home residents. The New England Journal of Medicine. 1998;339:875-82. 9. bpac NZ Looking back, looking forward: key messages 2007 2011. May 2012. RNZCGP MOPS Programme 2011-2013. Health Hawke s Bay Amitriptyline vs Nortriptyline Application June 2012 3
Application for Endorsement of CQI (Clinical Audit) Activities for MOPS Credits Allocation APPENDIX 1: DATA AUDIT SHEET FOR PATIENTS PRESCRIBED AMITRIPTYLINE FOR NEUROPATHIC PAIN (CYCLE 1 & 2) Patient Other comments / notes Number 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 TOTAL Is there documented evidence of a READ code for amitriptyline indication? Is amitriptyline prescribed for neuropathic pain? For those patients treated for pain with amitriptyline; is there documented evidence of consideration of benefits verses risks for continuing on amitriptyline or patient changing to nortriptyline? % (Yes) Aim 80% cycle1 100% cycle2 80% cycle1 100% cycle2 RNZCGP MOPS Programme 2011-2013 Health Hawke s Bay Amitriptyline vs Nortriptyline Application June 2012 4
Application for Endorsement of CQI Activities for MOPS Points Allocation APPENDIX 2: CLINICAL AUDIT TOOL Review of patients prescribed amitriptyline for neuropathic pain 1. Pharmacological management of neuropathic pain. Best Practice Journal 2008[Internet];16:13-15[Cited 11 June 2012]. Available at: http://www.bpac.org.nz/magazine/2008/september/neuro.asp 2. Kristen Jefferies. Treatment of Neuropathic Pain. Semin Neurol. 2010[Internet];30(4):425-432. [Cited 11 June 2012]. Available at: http://www.medscape.com/viewarticle/730671 RNZCGP MOPS Programme 2011-2013. Health Hawke s Bay Amitriptyline vs Nortriptyline Application June 2012 5