Trimipramine Review - Collaborative Project (2018)

Bromley CCG, Oxleas NHS Foundation Trust

Introduction

Bromley CCG had the highest number of trimipramine items dispensed in England at Aug 2016. Trimipramine is an old tricyclic antidepressant and newer safer treatments are recommended by NICE, it has also become prohibitively expensive. Trimipramine was also subsequently included in NHS England's list of "Items which should not routinely be prescribed in primary care". Aims of the project:

• review patients with a view to stopping or switching to safer more evidence-based treatments
• reduce risk of adverse effects
• reduce anticholinergic burden
• reduce risk of hospital admission
• improved patient care involving specialist mental health teams
• reduce costs, releasing resources for other medicines.

How was the project established? / How is it currently being established?

Pharmacists from the CCG Medicines Management Team supported some higher prescribing practices to review their patients. This resulted in some reduction in prescribing, however it also highlighted a number of other issues including:

• patients who had been prescribed trimipramine a number of years ago, sometimes decades, with uncertain diagnosis;
• some patients who had more complex mental health issues and there were concerns that stopping or switching from trimipramine could have a serious negative impact on the patient.

These initial findings were discussed at the local primary care prescribing committed and with the local mental health services provider, Oxleas. It was agreed to commission a time-limited collaborative service with Oxleas to review the more complex patients.

A summary of the pathway:

CCG MM pharmacist identified patients being prescribed trimipramine, discussed cases with GPs where some changes were made;

for more complex patients, including those with uncertain diagnosis, the CCG MM pharmacist completed a referral form and sent to Oxleas MH pharmacist:

• Oxleas MM pharmacist undertook notes review, and where appropriate discussed with consultants any recommendations;
• domiciliary visits were also undertaken by the Oxleas MM pharmacist, where patients were not able attend clinic/surgery;
• recommendations were agreed with consultant/GP and patient as appropriate;
• CCG MM pharmacist continues to follow up any outstanding actions to ensure that recommendations have been implemented and remain appropriate for individual patients;
• where practices employ a clinical pharmacist, they have also been involved in supporting this project.

Who are the main beneficiaries of the project? How would they benefit?

Patients are prescribed safer, more evidence-based medicines with confirmed diagnoses. Some patients were stopped and did not need alternatives, reducing the risk of adverse effects, reduced risk of hospital admissions.

This project has so far achieved a reduction in prescribing for this drug from its peak in Aug 2016 of 180 items, to 63 items in Mar 2018. A further reduction is expected while the remaining patients are being followed up.

What were the main outcomes and / or achievements of the project?

Improved patient safety, reduced risk of adverse effects eg falls, dementia, and reduced risk of hospital admission.

Reduced prescribing cost of up to £50k per month.

GPs, patients and pharmacy colleagues all benefitted from the collaborative working and access to specialist support.