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Medicines Management Team


Esomeprazole (Nexium)/ rabeprazole (Pariet) therapeutic switch

Issue date: Review date: Page: File reference:

5th January 2011 5th January 2012 1 of 5


Esomeprazole (Nexium) and rabeprazole (Pariet) tablets The background information to your tablets Esomeprazole or rabeprazole are tablets that have been prescribed to you to help decrease acid production in your stomach to reduce the symptoms and complications from conditions such as indigestion and ulcers. At present the NHS spends over 100 million every year on this class of medicines, called Proton pump inhibitors (PPIs), in England and Wales. Highlighted nationally for many years, the prescribing of PPIs is one area where significant efficiencies could be made by carefully considered changes in prescribing practice. The total cost of PPIs prescribed in Primary Care on the Isle of Wight in 2009/10 was around 453,000. Omeprazole and lansoprazole are medicines which are similar to esomeprazole and rabeprazole, but because theyve been available for prescribing for a much longer period, the original manufacturers of omeprazole and lansoprazole have since lost their exclusive right to produce these medicines (their patent has expired), and they have subsequently become available from many different manufacturers. The competition from these alternative manufacturers have driven prices for lansoprazole and omeprazole down markedly compared to the newer drugs esomeprazole and rabeprazole. Recently, the sole manufacturer of pantoprazole also lost its right to exclusively market this product and therefore can now be produced from other manufacturers, again the price of this drug has also fallen rapidly. According to guidelines from the National Institute for Health and Clinical Excellence (NICE) there is currently no reason to use expensive PPIs in preference to any of the other PPIs available when compared at appropriate, equivalent doses. Furthermore, it is highlighted that the PPIs most recently marketed on the NHS (esomeprazole and rabeprazole) offer no advantage in clinical effectiveness over established PPIs, plus there is also less evidence of long-term safety. To summarise, NICE recommend that the least expensive, appropriate, PPI should be used. On this basis generic omeprazole, pantoprazole and lansoprazole are currently suitable choices. (NICE 2004) (Dyspepsia: Management of dyspepsia in primary care. Clinical guideline No 17.) Itemised below is how much the NHS currently pays for PPIs: Omeprazole 20mg capsules - 1.68 for 28 capsules Pantoprazole 20mg tablets - 1.50 for 28 tablets Pantoprazole 40mg tablets - 2.42 for 28 tablets Lansoprazole 15mg capsules - 1.37 for 28 capsules Lansoprazole 30mg capsules - 2.08 for 28 capsules This compares to the cost of rabeprazole and esomeprazole as follows: Esomeprazole 20mg tablets - 18.50 for 28 tablets Esomeprazole 40mg tablets - 25.19 for 28 tablets Rabeprazole 10mg tablets - 11.56 for 28 tablets Rabeprazole 20mg tablets - 19.55 for 28 tablets By switching as many patients as possible, who are felt suitable for the switch, from esomeprazole or rabeprazole to either pantoprazole, omeprazole or lansoprazole, the Isle of Wight PCT could save around 118,000 per year, if prices continue at the same level. We are sure you would agree this money could be better reinvested in supporting other NHS services. The current financial climate means we have to look at every area to ensure value for money without compromising the care and treatment we provide to patients. This is why the Primary Care Trust (PCT) and the Medicines Management Team is so keen to perform this initiative. This does not mean that we are choosing medication that is less effective, it just means we want to pay for medicines which are the best value for money whilst achieving effective treatment of medical conditions. 2

The Medicines Management Team consists of dedicated pharmacists, pharmacy technicians and experienced nurses. Pharmacists are experts in medicines and are highly trained in all aspects of medicines and healthcare. Whilst we recognise that these medication changes may cause some anxieties and concerns, we try to minimise any risks that may be caused. On pages 4 and 5 we have detailed the process by which this medication switch has been carried out. We work closely with GP colleagues and hospital specialists and would like to reassure you that these professionals have been involved in the decision making process to change this medication. Members of the Medicines Management Team are available to help answer any queries you may have about your medicines. If you have any concerns, or you have an unanswered question, we would like to hear from you. Please do not hesitate to contact us on telephone number 01983 534271.

OBJECTIVES To identify all patients who have esomeprazole and rabeprazole on their repeat prescription, and who are suitable to be switched to a more cost-effective PPI. To change the medications safely and efficiently, whilst trying to minimise any risks and problems caused by the switch. To inform patients of the change to their treatment, and provide them with the necessary information to allow them to continue receiving safe, effective treatment for their medical condition. SCOPE To include all patients prescribed esomeprazole and rabeprazole tablets, except for those patients who are classified in the exclusion criteria (see below). Patients who meet the exclusion criteria are not suitable for the switch. RESPONSIBILITIES A GP at each GP Practice, usually the Lead GP for prescribing, must authorise the work to be carried out in the Practice. The Medicines Management Team are responsible for identifying patients, sending letters, record keeping and holding any relevant patient clinics. The Medicines Management Team are responsible for making information available on the PCT website for patients to refer to. PREPARATION Each GP Practice Manager and Lead GP will be contacted outlining the details of the proposed switch programme accompanied by its Standard Operating Procedure. A written reply approving the switch must be obtained before starting THE PROCESS detailed below. Each GP Practice will agree a patient letter explaining the reason for the change to their medication. GP Practice staff should be made aware of this initiative so they can provide information to patients, as and when required. Local pharmacies will be notified in advance to enable them to review stock levels, so as to minimise the risks of the medication not being stocked. Pharmacies are then in a good position to advise patients who have had their medication changed. A date to perform the switch on the GP Practices computer held records, and any clinics considered necessary will then be agreed.

THE PROCESS Stage 1: Identify patients taking esomeprazole and rabeprazole tablets using Vision (this is the GPs computer system where your notes are held) We use a system called Vision to identify patients currently receiving a repeat prescription for esomeprazole or rabeprazole. A report may be sent to the GP Practice indicating the number of patients currently prescribed the medication and potential savings if the switch is undertaken. Stage 2: Review Medical History Patients drugs and medical history will be reviewed to find out if there is any reason they should be excluded from the change. Stage 3: Exclusion criteria Patients that should not be switched: Patients with an intolerance/ adverse reaction to the proposed new medication. Patients whom by the judgement of the clinician undertaking the change, would be disadvantaged by the switch for any reason. 4

Patients who have been previously been initiated on the proposed medication and who have not had a therapeutic response.

Stage 4: Authorise the change and add new medication An entry will be made into the Vision medical records for each patient outlining the change of medication agreed with the GP Practice, and the identities of the Medicines Management Team members carrying out the change. The name of the new medication is added to the repeat prescription of the patients medical record, checking the dose and quantity of tablets are appropriate. For patients taking esomeprazole and rabeprazole the following alternatives will be considered: o Esomeprazole 40mg tablets to be changed to omeprazole 20mg capsules 2 daily. o Esomeprazole or rabeprazole 20mg tablets to be changed to lansoprazole 30mg capsules 1 daily, or pantoprazole 40mg tablets 1 daily, or finally omeprazole 20mg capsules 2 daily. o Rabeprazole 10mg tablets to be changed to lansoprazole 15mg capsules 1 daily, or pantoprazole 20mg tablets 1 daily, or omeprazole 20mg capsules 1 daily. Stage 5: Remove the old medication The dose and quantity of the new medication is checked carefully before deleting the old medication. Changes to medication are entered into patients notes only when all of above criteria are met. Stage 6: Prepare the letter to the patient A personalised letter is sent to each patient, advising of the reason for the change to their medication. Great care is taken to make sure we highlight the name of the old medication and the new medication, plus the rationale for change on the letter. Patients are invited to attend a clinic or contact the team with any concerns or questions they may have. In doing this it helps to reduce the workload of the GP Practice staff. Stage 7: Follow up Patients should not notice any difference when changing over to the other PPIs recommended, however, if it is felt this change has caused any new side-effects or has caused their condition to become less well controlled, then advice from the GP should be sought.