Summary of the example
This project was led by medicines optimisation pharmacists (MOPs) working in GP practices across West Hampshire CCG (WHCCG). The review was undertaken following a serious incident and subsequent death of a patient from amiodarone-related pulmonary complications.
480 patients were identified as having a regular, repeat prescription for amiodarone. Following a review of the clinical records my the MOP, and a face-to-face review of the patient by the GP and/or a cardiology specialist, a decision was made regarding the ongoing need for the drug. Of the 480 patients reviewed, 153 pts (32%) had their treatment reduced or deprescribed.
Why we think it’s important
Amiodarone is an effective antiarrhythmic drug, often used in the treatment of paroxysmal atrial fibrillation (PAF) and ventricular tachycardia (VT). Unlike most other antiarrhythmics, it is safe in heart failure. However, its use is limited by toxicity, especially in the long-term and current national guidelines do not recommend it as a first line option for rhythm or rate control in atrial fibrillation.
In view of its specialist nature, amiodarone is almost always initiated in secondary care but is often continued in primary care without clear indications recorded.
It is important that any patients still requiring amiodarone are managed safely, from initiation through to long term use and routine monitoring and that as part of regular medicines reviews, amiodarone is considered for de-prescribing if other medicines would be more appropriate and/or safer or the diagnosis is not clear.
Learn more about the example
Aims and objectives of the work
The aims of the project were four-fold:
- To ensure there is a clear indication for amiodarone therapy and that this is recorded in the patient notes
- To deprescribe amiodarone if not indicated, in agreement with the specialist in secondary care
- To check if on-going therapy is indicated
- Check for adverse effects and signs of toxicity
- Monitor patients 6 monthly
- Check amiodarone dosage
- To check for drug interactions
Electrophysiologists and cardiologists in the Wessex Cardiology Forum were consulted about the work and were instrumental in providing clinical leadership to the initiative.
Guidance about place in therapy and appropriate use of amiodarone was agreed and an information sheet was produced to support prescribers. In each practice a search was carried out to identify patients prescribed amiodarone on repeat prescription.
A medication review checklist was devised for the MOPs to use with each review highlighting any potential drug-drug, drug-disease interactions or other problems with the medication regime.
The MOP in each practice discussed the indications for treatment with the patient’s GP and if there was no clear information in the patient record about ongoing need for amiodarone, the checklist was sent to the initiating clinician in secondary care for further review.
Once a response was received from the initiating clinician, the patient was seen by their own GP and a decision was made about the need for ongoing amiodarone therapy with the outcome documented in the GP clinical record.
The total numbers of patients reviewed in this way and the outcomes regarding decisions to continue treatment were recorded and collated at the end of March 2017.
A total of 480 patient records were reviewed from all 50 practices in the CCG. After discussion with the patient’s GP and/or a cardiology specialist, the need for ongoing amiodarone treatment was clearly documented in the clinical record. At the end of March 2017, a total of 153 patients (32%) had their treatment reduced or deprescribed as a result of the review.
In addition the District Prescribing Committee (DPC) sanctioned a change of status for amiodarone from Green to Amber to highlight the need for good communication and shared-care between primary and secondary care, especially in relation to indication for prescribing amiodarone and duration of treatment.
An outline of the process developed by West Hampshire CCG Medicines Optimisation Team.
National guidance, data and publications
Amiodarone has been used to control atrial fibrillation since the 1970s. However, NICE CG 180 states that amiodarone should not be offered for long-term rate control. In addition the NICE guidance states that for long term rhythm control, amiodarone may be considered for people with left ventricular impairment or heart failure if beta blockers are contra-indicated.
Interim co-director, South West Medicines Information and Training, NHS England South