September's outputs from Keele's 'Medicines Optimisation' team

Another busy month for the team at Keele University's Centre for Medicines Optimisation, trying to get our antibiotics-themed educational outreach pack (we call them our Actions for Commissioning Teams [ACT] packs) out in time for the winter peak in antibiotic prescribing. This latest ACT pack actually addressed three 'antibiotics-related' QIPP topics from the medicines and prescribing team NICE:

1. Antibiotic prescribing, in particular the use of broad-spectrum antibiotics 
2. Three-day trimethoprim for uncomplicated UTIs in women
3. Minocycline for acne

In relation to the prescribing data provided to our CCGs and practices on the above topics, the variation in use of co-amoxiclav across CCGs was notable, as was use of minocycline (although the prescribing data indicate a marked decline in use of the latter in recent months). 
 

Our latest Monthly Script newsletter has also just been published (an 'open-access' version of the Monthly Script is available on our website).  In this latest newsletter, we highlight the recent update to the NICE guideline on Urinary Incontinence in women.  The updated guideline contains several changes concerning treatment-choice, including a new recommendation that immediate-release (I/R) tolterodine and once-daily darifenacin are now also both recommended as first-line antimuscarinics, in addition to I/R oxybutynin, for women with overactive bladder or mixed urinary incontinence).(We note that I/R tolterodine is now available as a lower cost generic and that there is evidence to suggest that it is associated with a lower risk of dry mouth than I/R oxybutynin).
In light of these new recommendations, we took the opportunity to look at current levels of use of these first-line treatments in our subscriber CCGs (calculated as number of items of I/R oxybutynin, I/R tolterodine and darifenacin as a % of antimuscarinic items). Use ranges from 10 to 36% currently across our subscriber CCGs. We also reported current average spend on antimuscarinincs (reported as Net Ingredient Cost [NIC]/antimuscarininc item) and estimated annual savings for CCGs based on a move to the 25th percentile value for NIC/item (amounting to >£200K for some subscriber CCGs). 

The Monthly Script also reported findings of the TIOSPIR trial, which appear to offer some reassurance over the safety of tiotropium delivered via the Respimat device for the treatment of COPD.  The trial, which  was a randomised, double-blind, head-to-head comparison of tiotropium Respimat and triotropium Handihaler, was undertaken following reports of a numerical increase in all-cause mortality with tiotropium Respimat compared with placebo (e.g. link to exisiting MHRA safety advice on tiotropium Respimat).  TIOSPIR randomised patients with COPD (n = 17,135) to either tiotropium Respimat (2.5 mcg or 5 mcg once daily) or tiotropium HandiHaler (18 mcg once daily).  The primary safety outcome for this study was risk of mortality (non-inferiority analysis). During a mean follow-up of 2.3 years, tiotropium Respimat 2.5 mcg/day and 5 mcg/day were both found tobe non-inferior to tiotropium HandiHaler for risk of mortality (Respimat at a dose of 5 mcg vs. HandiHaler:hazard ratio, 0.96; 95% confidence interval [CI], 0.84 to 1.09; Respimat at a dose of 2.5 mcg vs. HandiHaler: hazard ratio, 1.00; 95% CI, 0.87 to 1.14).

We also highlight a recent analysis of use of lipid lowering drugs for primary prevention of CVD amongst UK General Practices, which suggests that that over half of patients prescribed such treatments do not meet current guideline criteria for treatment. The study also found considerable underuse of the drugs in eligible patients.