Dr Peter Hayes
Lecturer in Primary Care
NUIG
 Generic
Prescribing HOT TOPIC
 Horizon Gazing for Nurse Prescriber in
Primary Care
 Prescribing pitfalls / Quality Prescribing in
Primary Care and generally
 20
Year patents : Get the drug approved for
‘use’ by Expert Committees/Clinical Trials
usually 10 years
 Generic medicines allowed after patent up
(10-20 years).This allows production by any
company, based on the released compound
formula.
 Eg: Viagra Brand........Sildenafil Generic or
INN ‘International Non-Proprietary
Name’(Pfizer Cork)
Are as effective as branded medicines ? IMB/EMA
approve studies done by generic companies to
license their drugs (20% Ireland V 80% UK from
National centre for Pharmaco-Economics NCPE
2009)
 Patient safety (1 name, everyone reads from
the same page,but branded generics can muddy
the water
 Up to 80% less in cost. ( See some comparisons
later ) No costs of ‘discovery’ with generics only
cost being manufacturing. 1.9 Billion/17% total
spend ,(OECD 2010) GMS Drug cost. Up 0.4 Billion
since 2005.Switching to generics when suitable
could save 100 M /year ( DOH/HSE)
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Pharmacy are now dispensing cheaper generics to
GMS patients despite the prescription showing a
brand named drug. This is a legal grey area as a bill
on this does exist but is waiting enactment.
Bioequivalence (Pharmacokinetic term) does not
equal replication , may be slight chemical
differences/Esthers/Flavours/Non active ingredients
?? (will look at this later in more detail)
Colour, shape, tablet size and confusion
Ireland pays more for Generics, Long Standing
Government –Pharma agreements / Pharmacy
(APMI/IPHA) v HSE cost/ profit issues also. Up to 98%
originator drug 2008. New deal 2012 , 3 years,70 %
,then drops to 50%, of originator drug after 1 year
 GMS
Acid 120 M
 COPD 110 M
 ACE Inhibitors etc 75 M
 Psycholeptics and Anti Psychleptics 150 M
 Lipids 160 M
 50 % of cost entire GMS regular drugs budget
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Pharmaceutical substance
Proprietary cost**
Generic cost**
GMS DATA THROUGH MIMMS MARCH 2009 / NMIC Data
Lansoprazole 30mg/day
36.29E
23.30E 2E UK !
Omeprazole 20mg/day
27.41E
21.23E
Doazosin 4mg 40mg
18.00E
12.00E
Donezepil 10mg/day
113.27E
70.66E
Venlafaxine prolonged release 75mg/day
28.54E
17.47E
Alendronic acid 70mg once weekly
29.97E
20.30E
 Using
a generic drug to treat hypertension
and heart failure, instead of branded
medicines from the same class, could save
the UK National Health Service (NHS) at least
£200 million in 2011 without any real
reduction in clinical benefits.
 That is the key finding of a systematic
review, statistical meta-analysis and costeffectiveness analysis published online by
IJCP, the International Journal of Clinical
Practice.
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Differing bioavailability.(drugs with narrow therapeutic index)
Carbamazepine/AEDS,Lithium,Theophylline,Ciclosporin
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Modified-release preparations Nifedipine,Diltiazem,Morphine
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Medicines with multiple ingredients HRT,COC,CREON
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Similar medicines with different administration devices Inhalers
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Different preparations of same medicine
with different indication(s) Bisoprolol,Duloxetine
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Medicines of biological origin GH, EPO
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How do nurse prescribers integrate prescribing in practice: case studies in
primary and secondary care (D Bowskill 2012 J of Clinical Nursing) Interview
with 29 N Prescribers
‘More Drugs prescribed in Primary Care, Less restrictions than secondary care
colleagues but more Doctor double checking’
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Assessing the contribution of prescribing in primary care by nurses and
professionals allied to medicine: a systematic review of literature S Bhanbhro.
BMC Health Services Research 2011. Litt Review Non Medical prescribing, 19
papers
’Little on clinical outcomes but nurse prescribing was widely acceptable/
satisfaction. Big Research gaps and thus policy lags’
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Consultations between nurse prescribers and patients with diabetes in primary
care: A qualitative study of patient views. KL Stenner. Int J N studies 2011.
interviews DM patients in 6/7 PC settings
‘DM care works well,but some issues re S/E s OHA’s. Consult length etc./ Pt centred
care better’
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Effects Of Nurse Prescribing Of Medication: A Systematic Review M Van Ruth,
Internet J of Health Care Administration 2008. Sys Review Netherlands
‘Similar to physicians in satisfaction rates/ review rates etc info given . Bias in
studies
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1700 Practice Nurses
 213 ANP/CNS
 6 N.P.s
 9 in training to be R.N.P.’s
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Collaborative practice agreements and GMS
scripts. Period of Registration and prior to that
University period / examination / Supervisor
(HSE Guidance Doc 2011)
 6-7 months education through a University
programme , 6-7 months Drug and Therepeutics
and CPA agreements ( Ruth Morrow, Journal IPNA
2011 )
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 Nurse
Independent Prescribers 19,000.
(More Primary Care, Full BNF, still local
restrictions in some areas and reluctance
to be unsupervised )
 Community
Practitioner Nurse Prescribers
( Community Formulary ) District Nurses
etc.
 Nurse
Supplementary Prescribing (Once
diagnosed DM/Asthma )
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Chronic Care Asthma meds/ DM meds/CVS
Oral contraceptives / Sexual health
Specific guideline based consults. Sore Throat /COPD
Cellulitus/Smoking cessation
Vaccines for Travel
Chronic care House calls/ Chronic care or subacute care
Nursing home visits
INR management ,Warfarin prescription, Ear care
Expansion makes sense, evidence will make stronger
case with time.
Discussion on roles ‘ICGP’
Training joint programmes ICGP/Universities running
Referral for RNP ?
 Prescribing
is a technically difficult and
morally complex issue Royal Pharmaceutical
Society 1997
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Re -Check dosing, contraindications and potential side effects
(e.g. from the Summary of Product or in a recognised formulary,
such as the BNF) prior to issuing prescription.
- Check what other medicines the patient is taking, including
non-prescription items, which may interfere with the new
medicine ( Look it up )
- Refer to check list of common drug-drug interactions, when
patients are taking several medicines.
- Ensure that the prescription is legible – it may be
misinterpreted if it cannot be read
- Advise patients of possible, likely and probable side effects and
encourage them to report back any problems
- Respond promptly (either reducing dose / discontinuing drug) to
a patient’s concern /ADR
- In the event of any side effect, consider reporting it to the
regulatory authority (www.imb.ie )
Patients must be seen at least six monthly
Printers and checking what you click and what prints
Sign scripts together in consults or at a specific break period. No
corridor scripts
Take calls from pharmacies as ‘Good grace’, they are probably
right!
Phone call/envelope scripts. Best practice to see.
Give supplementary directions in pen even if printing ( Adds
certainty to your script / get to check over it )
Review need for nay med at each visit…poly-pharmacy in the
elderly…you may be the only one to question a med ( Others may
not see what you see ) Back yourself
Write clearly even if it pains you
Audit yourself intermittently. ( Notes , scripts ) Look back at a
couple each day after a a session. Formal audit too!
Look up, look up and look up doses/ drugs/dilemmas/interactions
for all new drugs. Google +
Discuss cases amongst peers and co prescribers.
 Practice
Formulary and updating of this
 P Drugs ( Personal Drugs )...WHO Guide to
Good Prescribing Look at each drugs active
substance / dose /dosing schedule/duration
/effectiveness/safety
 Be uptodate.com Books / Bulletins/ Word of
Mouth/Reps/Journals
 Pimohamed BMJ 2004 : 6% admissions to
hospital re ADR’s
One quarter of adults (25%) use the internet as a
source of information about medicines.
 30% are attempting to diagnose health symptoms
 Half (49%) of those surveyed always seek advice
from a healthcare professional– typically a
pharmacist – before taking a new over the
counter medicine
 GPs (68%) and pharmacists (25%) are by far the
most trusted sources of medicines information
 75% patients read the product info and rest
mainly ask doc/ pharmacy about issues
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 PPI
< 2/12
 NSAID <3/12
 BDZ<1/12
 Drug duplication same class
 Inappropriate prescribing
 Transcribing a problem . Copying or using
another's route/dose /Mis-spelling/ Nursing
Home scripts . Nursing home kardex ?
Commonly copied by staff and asked to sign
 20%
of cases against GP are prescription
related
 Incorrect dose , route, strength, quantity ,
Contra-indications
 5% of all scripts illegible
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NSAIDS DO GENERALLY DO NOT GO WITH DM / RENAL PATIENTS
/CCF
Largactil v Lamictal..Spell and write clearly
Penicillan allergy or Aspirin/ NSAID bronchospasm
Oral /laryngeal Thrush from Steroid Inhalers ( Non disk ) used
without spacers
Sleepers/BDZ/Opiate analgesia repeats
Warfarin : Ciprofloxacin/Clarithromycin/NSAIDS ‘Just dont mix as
INR++’
Check all doses if not known to you and hold untill confirm
stranger doses etc.
Check all new drugs and inform yourself about them. NMIC
K+/Cr on all CCF patients
Statins and Anti fungals ( Myositis/Liver )
Istin and CCF swollen legs
Glucophage and Nausea ( initially )
Digoxin with amiodarone or verapamil
 Minister
of State with responsibility for
Primary Care (RS) was developing proposals
under the Misuse of Drugs legislation to
introduce stricter controls on
benzodiazepines and an initiative to tackle
overprescribing.
 HSE are making moves to monitor prescribing
patterns and to control repeat prescription
 GP’s x 3 at Fitness to Practice re BDZ
prescription.
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Medicalization of ‘stress’ and acute stress reactions
Importation illegally of non prescribed ‘benzos’
Sharing and selling of prescribed ‘benzos’ between the patient
population
Doctor burn-out in socially deprived area’s and repeat
prescribing as a symptom of that
Repeat prescriptions and their unchecked flow
Lack of local ability to provide support services to those
undergoing acute stress reactions
Inability of doctors to say ‘NO’ and be assertive
The ‘Conflict avoidance techniques’ and inability of doctors to
insist on taper of doses and cessation of prescriptions after their
initial short term use
Lack of knowledge on benzodiazepine tapering regimes
Mild insomnia in the elderly seen as abnormal
Public demand for a ‘potion’ for every possible worry/ailment
Addiction +++ and a life time of use as a ‘stress
crutch’
 Prison : We see 25 % of new committals where
BDZ played a ‘role’ in the crime. Up to 40% take
BDZ as a normal part of their lives. 2-3 new
prison committals a week may take 100-150 mgs
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diazepem daily
Children are fed BDZ to stop them crying. (Many
case reports)
 Overdose reports especially with alcohol and
other drug use
 Repeat script workload and staff stress about
repeat scripts
 Social cost $$$$ Prison beds, property damage,
medication costs and de-tox costs, and family d
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Just say NO. If everybody stops ‘starting’ them
then nobody has to keep ‘stopping’ them
 Diversionary tactics: I am here to provide
medical care for you and will do that at any time
for you ,but I D’ONT prescribe BDZ in this
practice
 Use S.S.R.I for anxiety relief and ‘sleeplessness’
short term can be helped with Phenergan 25-50
Mgs nochte or Amitriptiline 10-25 mgs nochte
Mirtazepine 15-30 mgs nochte (if associated
with anxiety)
 Maximise the practices support network for
acute stress reactions
 Specific Detoxification , withdrawal plans ,
choose your patient group carefully.
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