Patients prescribed medications on a repeat basis need regular review and monitoring. Prescribing medications at usual doses for patients with impaired kidney function can have a negative impact on a patients' health outcomes by increasing the burden placed on the kidney and can affect medication efficacy (British National Formulary [BNF], 2022a). For certain medications, it is vital to monitor kidney function to ensure the correct dose is prescribed, and the medication is still appropriate for use.
In a GP practice, the clinical pharmacist noted that whilst completing medication reviews, some medications prescribed (particularly for those with declining renal function) were often not prescribed at the most appropriate dose for their kidney function.
A drug safety alert form was also released (Electronic Medicines Compendium, 2019), highlighting the importance of using the appropriate estimation of renal function to avoid the risk of adverse drug reactions when prescribing. Medication dosage should be calculated using the most appropriate method, either estimated glomerular filtration rate (eGFR) or creatinine clearance (CrCl), calculated via the Cockcroft-Gault formula (BNF, 2022b).
To review both these elements and ensure that the appropriate method was used to inform the appropriate dose in patients with chronic kidney disease (CKD) 3-5 (those with moderate to severe impairment of function) (National Institute of Health and Care Excellence [NICE], 2021), an audit was undertaken by the clinical pharmacist in a GP surgery of around 10 000 patients.
The intention was to set up best practice advice within the surgery for those involved in prescribing. A repeat of this audit was conducted a year later to see if prescribing had changed, and to confirm which medication classes most frequently require dose adjustment.
Aims
To identify medications that were most likely to be prescribed at inappropriate doses in patients with CKD 3-5, and to implement methods to improve patient care in this area by sharing results with clinicians involved in prescribing decisions including GPs and non-medical prescribers (NMPs).
Methods
A search of registered patients was completed using the surgery computing system, SystmOne. This identified all patients currently linked to a read code diagnosis of CKD level 3-5. The codes used are shown in Table 1. The resulting list was the cohort of patients to be included in the audit.
Table 1. SystmOne Codes used to identify patients with likely CKD 3-5
| SystmOne Codes used to identify CKD |
|---|
| XaO3t chronic kidney disease stage 3 with proteinuria |
| XaO3u chronic kidney disease stage 3 without proteinuria |
| XaNbn chronic kidney disease stage 3A |
| XaO3v chronic kidney disease stage 3A with proteinuria |
| XaO3w chronic kidney disease stage 3A without proteinuria |
| XaO3y chronic kidney disease stage 3B without proteinuria |
| XaNbo chronic kidney disease stage 3B |
| XaO3x chronic kidney disease stage 3B with proteinuria |
| XaLHI chronic kidney disease stage 3/stage 4 |
| XaLHJ chronic kidney Disease stage 4 |
| XaO3z chronic kidney disease stage 4 with proteinuria |
| XaO40 chronic kidney disease stage 4 without proteinuria |
| XaO41 chronic kidney disease stage 5 with proteinuria |
| XaLHK chronic kidney Disease stage 5 |
| XaO42 chronic kidney disease stage 5 without proteinuria |
The audit was conducted by a new post-clinical pharmacist who was undertaking the non-medical prescribing course, and had completed this by the time of repeat audit. This helped to inform good practice in prescribing for this cohort and highlight missed clinical opportunities to improve in future. It also meant good practice lessons could also be shared with existing and potential prescribers within the practice to optimise patient care.
Level 2 (without the patient, but with full access to their notes) repeat medication reviews were carried out by the practice clinical pharmacist. Level 2 reviews were chosen to allow queries to be discussed with the patient if required, but if there were no proposed interventions the patient did not need to be contacted. Outcomes of the reviews were collated on a spreadsheet for evaluation.
Information regarding use of the drug in renal impairment as listed in the Summary of Product Characteristics (SPC) and the BNF was used to support the reviews.
The initial audit was completed between November 2018–January 2019. To monitor prescribing practice, a repeat audit was completed between November 2019–March 2020 using the same method as above.
Ethical approval
The audit was undertaken within the scope of practice for the clinical pharmacist role. As this project is a clinical audit, guidance from the NHS Health Research Authority (HRA) does not require research ethics committee or HRA approval. The project was undertaken with support from the practice Caldicott Guardian. Medication reviews were not undertaken in a way that differs from those already approved in practice, except that the focus was on the impact of the medications on chronic kidney disease. Reviews conducted as part of the audit did not replace a wider medication review for these patients. Any suggested dose changes were discussed directly with the patient prior to implementation.
Initial audit results
225 patients were found in the initial audit search. Age ranges were reviewed (Table 2) to assess the correlation of CKD with age in the cohort. Kidney function generally declines with age (Weinstein et al, 2011). Of these:
- Three patients had not requested repeat medications for over 10 months – these may be considered ‘ghost’ patients who remain registered but not actively engaging with the surgery
- 17 patients were listed as being under the care of nephrology
- One patient was listed as undergoing dialysis.
Table 2. Patients coded with CKD 3-5 classified by age
| Patient age | Number |
|---|---|
| 40-50 | 3 |
| 51-60 | 12 |
| 61-70 | 23 |
| 71-80 | 64 |
| 81-90 | 82 |
| 91-100 | 40 |
Two patients with age unknown (due to errors in recording)
The repeated audit showed the following changes within the cohort (Table 3), likely due to patients ageing into the next classification, or the natural movement of patients between practices.
Table 3. Age of patients in the repeat audit, change from the previous audit shown in brackets
| Patient age | Number |
|---|---|
| 40-50 | 3 (=) |
| 51-60 | 11 (+1) |
| 61-70 | 27 (+4) |
| 71-80 | 66 (+2) |
| 81-90 | 88 (+6) |
| 91-100 | 32 (-8) |
| 100+ | 1 (+1) |
Two patients with age unknown (due to errors in recording)
The repeat audit included 46 new patients who either weren't coded with CKD level 3, 4 or 5 for the previous audit, or were not registered with the surgery last year.
Within this repeat audit cohort:
- 20 patients listed as being under the current care of nephrology, one patient referred as a result of this audit
- Two patients recently discharged from nephrology
- One patient awaiting review to the heart failure clinic, which will involve medication optimisation.
For patients under nephrology, the repeat audit looked at their repeat medications with the same scrutiny as those who are not under the care of the consultant. In the previous audit, this was not done as it was assumed that consultants would be aware of the medications their patients were taking and have approved them for continued use. Confidence to query this by the pharmacist was an element learned whilst undertaking the NMP course. Responsibility for prescribing repeat prescriptions sits with primary care and it cannot be assumed consultants will undertake in-depth medication reviews during the short time they have with the patient. To support good practice and collaborative working, advice was requested during the audit from nephrology consultants to clarify treatment plans, and gain advice for complex patients.
Medication changes were suggested by the pharmacist in cases where there was no clear benefit to using a dosage outside that recommended in the SPC (eg direct-acting oral anticoagulants [DOACs]) (Table 4). For the initial audit, the pharmacist completing the reviews was not a non-medical prescriber, so the suggestions needed to be discussed with a GP lead and the patient. These were then either implemented by the pharmacist, or if not approved, a read code was added to the patient's journal for future consideration during reviews.
Table 4. Medications with recommended changes in the initial audit
| Medication | Recommendation | Number |
|---|---|---|
| Simvastatin | Reduce to max 10 mg | 7 |
| Allopurinol | Reduce dose | 6 |
| Ramipril | Reduce dose to max 5 mg daily | 4 |
| Rivaroxaban | Reduce dose | 4 |
| Bendroflumethiazide | Query use under 30 eGFR | 3 |
| Alogliptin | Reduce dose | 2 |
| Ibuprofen | Review use in severe impairment | 1 |
| Losartan | Reduce to lowest effective dose | 1 |
| Ciprofibrate | Reduce to every other day | 1 |
| Ranitidine | Half normal dose under eGFR 50 | 1 |
| Lisinopril | Reduce to max 5 mg daily | 1 |
| Rosuvastatin | Reduce to max 5 mg | 1 |
| Fibrate | Reduce to max 67 mg | 2 |
Recommendations were also noted for patients whose kidney function did not yet require a medication change, but future decline may warrant this (Table 5).
Table 5. Medications where further review/ongoing monitoring was recommended
| Medication | Recommendation | Number |
|---|---|---|
| Butec | Monitor use | 3 |
| Furosemide | Use with caution | 6 |
| Isosorbide Mononitrate | Use with caution | 4 |
| Statin | Use with caution/reduce dose if further worsening function | 20 |
| Metoclopramide | Use lowest effective dose | 1 |
| Metformin | Review dose | 3 |
| Apixaban | Reduce if worsening CrCl | 1 |
| Dapagliflozin | Avoid if glomerular filtration rate drops under 60 | 1 |
| Empagliflozin | Avoid if consistently under 45 | 2 |
| Mirtazapine | Review dose as clearance reduced | 3 |
| Rivaroxaban | Consider reducing dose | 4 |
| Irbesartan | Use lowest effective dose | 1 |
| Hydralazine | Reduce dose in EGFR under 30 | 1 |
| Fentanyl patch | Monitor use | 1 |
| Methotrexate | Monitor Use | 1 |
| Paracetamol | Consider changing soluble to liquid | 1 |
| Tolterodine | Use half normal dose if worsening eGFR | 1 |
| Olanzapine | Review – initial 5 mg dose suggested | 1 |
| Propranolol | Use with caution/monitor use | 2 |
| Pregabalin | 400 mg – review max 300 mg | 1 |
| Ramipril | Review dose and reduce if appropriate | 7 |
| Telmisartan | Review strength if eGFR worsening | 3 |
| Verapamil | Review strength as under eGFR 30 | 1 |
| Bicalutamide | Review use if eGFR worsening | 1 |
| Codeine | Avoid due to accumulation | 1 |
| Digoxin | Review and reduce if needed | 1 |
| Enalapril | Consider reducing to max 10 mg | 1 |
| Gliptin | Review and reduce if worsening eGFR | 3 |
| Lercanidipine | Review benefit under eGFR 30/if worsening | 5 |
| Moxonidine | Review use under eGFR 30 | 1 |
| Perindopril | Review and reduce if worsening eGFR | 1 |
| Solifenacin | Review and reduce if worsening eGFR | 1 |
| Spironolactone | Review if worsening eGFR | 1 |
| Quinine | Review if worsening eGFR | 3 |
| Lisinopril | Review if worsening eGFR | 1 |
| DHC | Avoid due to accumulation | 1 |
| Diltiazem | Review if worsening eGFR | 1 |
| Telmisartan/HCL | Review if worsening eGFR | 1 |
| Gabapentin | Review – max dose 900 mg | 1 |
| Tramadol | Review and reduce if worsening eGFR | 1 |
| Alendronic Acid | Review use | 1 |
In the initial audit, 126 patients were considered to have no current action needed, either due to being on a medication that doesn't require dose reduction in renal impairment or already being on the most appropriate dose. Table 7 shows the number of suggestions made based on the most recent eGFR readings. In the repeated audit completed a year later, 227 patients were found with a read code of CKD 3-5.
Table 6. The findings from Tables 4 and 5 split into BNF drug classes to show those most commonly affected by renal prescribing considerations
| Drug Class | Recommendations |
|---|---|
| Gout treatment/prevention | 9 |
| NSAIDs | 1 |
| ACEiII | 6 |
| Cholesterol lowering medications | 31 |
| Diabetes | 11 |
| Diuretics | 21 |
| ACEi | 15 |
| H2 antagonists | 1 |
| DOACs | 9 |
| Opioids | 8 |
| DMARDs | 1 |
| Nitrates | 4 |
| Antiemetics | 1 |
| Antidepressants | 3 |
| Simple analgesics | 1 |
| Antimuscarinics | 2 |
| Cardiac glycosides | 1 |
| Antipsychotics | 1 |
| Beta blockers | 2 |
| Gabapentinoids | 2 |
| Antihypertensives | 1 |
| Calcium channel blockers | 1 |
| Bisphosphonates | 1 |
Table 7. Number of medication suggestions relating to the most recent eGFR
| eGFR range | Number of suggestions |
|---|---|
| 0-20 | 2 (patients under nephrology) |
| 21-40 | 76 |
| 41-60 | 52 |
| 61-80 | 2 |
| 80+ | 0 |
Suggested medication changes from the previous year's audit were re-reviewed to see if these had been actioned, or if they were still outstanding. If outstanding, the suggestion was evaluated to see if it was still appropriate or relevant, and actioned if necessary. Any change in eGFR from the previous audit was also noted.
In addition to repeating the audit, the clinical pharmacist had completed the NMP course. As a result of this, any recommended changes and actions within their scope of practice could be discussed directly with the patient, which helped to improve the speed of implementation. GP approval was sought if outside the area of the agreed scope of practice, or if there was a lack of confidence in implementing the change.
In the repeated audit, the patient was contacted directly by the pharmacist to discuss potential changes – this occurred via letter, telephone call, or face to face appointment to discuss the proposed change and rationale.
Monitoring
Monitoring of kidney function relies on up to date blood tests being taken, Tables 8 and 9 shows how recently these had been checked in this group of patients during the initial and repeat audits.
Table 8. Date of last kidney function blood test on initial audit
| Most recent eGFR taken: | Number of patients |
|---|---|
| Within 6 months | 135 |
| Within 1 year (longer than 6 months) | 34 |
| Within 2 years | 42 |
| Within 3 years | 6 |
| Within 4 years | 4 |
| Within 5 years | 1 |
| Within 6 years | 3 |
Table 9. Date of most recent kidney function blood test for repeat audit
| Most recent eGFR taken | Number of patients |
|---|---|
| Within 6 months | 128 |
| Within 1 year (longer than 6 months) | 68 |
| Within 2 years | 33 |
| Within 3 years | 2 |
| Within 4 years | 3 |
| Within 5 years | 1 |
| Within 6 years | 1 |
| Within 7 years | 1 |
A robust recall system should be in place to ensure regular measurement of kidney function, allowing appropriate prescribing information to be available for patients where renal function may be expected to change and/or decline. A stable system also allows the stability of renal function to be determined, avoiding instances where one out of range result is used to implement medication change.
22 patients had not repeated blood tests since the previous audit, meaning up to date recommendations could not be made. In patients who had a repeated blood test from last year, 86 had an increase in eGFR.
Results from repeat audit:
Tables 10 and 11 show the interventions which took place on the repeated audit. Table 10 shows new recommendations, and Table 11 follows up the recommendations made from the first audit.
Table 10. Medications with recommended changes that were implemented (from the repeat audit only)
| Medication | Recommendation | Count |
|---|---|---|
| Rivaroxaban | Reduced from 20 mg OD to 15 mg OD | 5 |
| Allopurinol | Reduced from 300 mg to 100 mg | 3 |
| Fenofibrate | Reduced to 67 mg OD | 2 |
| Simvastatin | Switched to atorvastatin | 2 |
| Pravastatin | Reduced from 40 mg to 20 mg (lowest dose recommended) | 1 |
| Bezafibrate | Changed from m/r to standard release | 1 |
| Ramipril | Reduced from 10 mg to 7.5 mg, with a view to reduce to 5 mg | 1 |
| Ramipril | Reduced from 5 mg BD to 2.5 mg BD | 1 |
| Ramipril | Reduced from 10 mg OD to 5 mg OD | 1 |
| Ramipril | Reduced from 5 mg OD to 2.5 mg OD | 1 |
| Rosuvastatin | Reduced from 10 mg to 5 mg | 1 |
| Ranitidine | Reduced to 150 mg OD | 1 |
| Alogliptin | Reduced from 25 mg to 12.5 mg | 1 |
| Solifenacin | Reduced from 10 mg to 5 mg | 1 |
| Alendronic Acid | Stopped | 1 |
Table 11. Medications with suggested further review or ongoing monitoring (from repeat audit only)
| Medication | Recommendation | Number |
|---|---|---|
| Azathioprine | If drops below eGFR20, to reduce dose by 25% | 1 |
| Bendroflumethiazide | Review/stop if drops below eGFR 30 as unlikely to be of benefit | 5, 1 (CO) |
| Nitrofurantoin | Monitor use if falls below eGFR 30 | 1 |
| Ramipril | Monitor BP and reduce to 1.25 mg if necessary | 1 |
| Ramipril | Reduce/review dose if worsening | 7, 3(CO) |
| Losartan | Review and reduce dose if eGFR drops below 20 | 2 |
| Lercanidipine | Monitor and reduce if worsening eGFR | 1 |
| Nitrazepam | To use with caution – discussed with patient | 1 |
| Dapagliflozin | To review dose if drops below eGFR 60 | 1 (CO) |
| Rosuvastatin | To review dose if drops below eGFR 60 | 1 (CO), 1 |
| Irbesartan | Reduce if worsening | 1 |
| Pregabalin | Review as taking over max 300 mg recommended – to review with patient | 1 (CO) |
| Codeine | Reduce strength if worsening eGFR | 2 |
| Mirtazapine | Reduce to lowest effective dose if possible | 4 |
| Fentanyl patch | Monitor and reduce if eGFR worsening | 1 |
| Propranolol | Review and reduce if worsening | 2 |
| Hydralazine | Under cardiology and nephrology – clarify whether to maintain dose or reduce as per manufacturer | 1 |
| Oxybutynin | Caution if worsening eGFR | 1 |
| Lisinopril | Monitor and review if worsening eGFR | 2 |
| Rivaroxaban | Monitor bleed risk, if worsening, reduce from 20 mg OD to 15 mg OD | 1 |
| Butec patch | Invitation sent to patient to discuss/reduce | 1 |
| Esomeprazole | Switch if worsening | 1 |
| Alogliptin | Reduce if worsening | 1, 1 (CO) |
| Empagliflozin | Reduce if consistently below 45 | 2 |
| Ciprofibrate | Consider reducing to every other day if worsening | 1 |
| Alendronic Acid | Review mobility and reduce if worsening | 2 |
| Metformin | Review if worsening | 3 |
| Gabapentin | Reduce if worsening | 1 |
| Moxonidine | Review/reduce of worsening | 1 |
| Rivastigmine | Caution with use | 1 |
| Furosemide | Review if kidney function not stable | 2, 1(CO) |
| Telmisartan | Review if worsening | 3 (CO) |
| Digoxin | Review if worsening | 1 (CO) |
| Allopurinol | Review if worsening | 1 (CO) |
| Solifenacin | Review if worsening | 1 (CO) |
| Perindopril | Review if worsening | 1(CO) |
| Co-amilozide | Review if worsening | 1 |
| Lansoprazole | Reduce to 50% of usual dose | 2 |
| Apixaban | Monitor and reduce of worsening CrCl | 1 |
| Clone | Reduce dose/stop | 1 |
| Diltiazem | Reduce if worsening | 1(CO) |
| Imipramine | Letter written to review with patient | 1 |
Table 12 shows actions that were recommended on the original audit, and have since been implemented. Some of these interventions were completed by GP review or via hospital advice.
Table 12. Recommendations implemented from last year
| Medication | Recommendation | Number |
|---|---|---|
| Rivaroxaban | Reduced from 20 mg OD to 15 mg OD | 3 |
| Simvastatin | Switched from 40 mg to atorvastatin 20 mg | 2 |
| Ramipril | Stopped by hospital | 1 |
| Ramipril | Reduced by hospital | 1 |
| Neditol | Stopped by GP | 1 |
| Losartan | Reduced to 50 mg by GP | 1 |
| Allopurinol | Reduced 1 patient from 200 mg to 100 mg, 1 from 300 mg to 150 mg | 2 |
| Mirtazapine | Reduce dose to lowest tolerate, one patient reduced by 15 mg to 30 mg, one stopped | 2 |
| Methotrexate | Changed from oral to injected by hospital | 1 |
| Metformin | Reduced from 1 g to 500 mg ON | 1 |
| Enalapril (RR) | Stopped | 1 |
| Apixaban (RR) | Stopped | 1 |
| Propranolol (RR) | Stopped | 1 |
| Alendronic Acid (RR) | Stopped | 1 |
| Bendroflumethiazide (RR) | Stopped | 1 |
| Simvastatin (RR) | Stopped | 1 |
| Co-tenidone (RR) | Stopped | 1 |
| Lisinopril (RR) | Stopped | 1 |
| Codeine (RR) | Stopped | 1 |
The results of the repeat audit were compared with the original audit, which found:
- 13 patients had recommendations on both audits
- 106 patients reviewed had no recommendations on either audit.
- Eight patients had recommendations in the repeat audit, who were not part of the patient list last year
- 39 patients who were included last year with no recommendations had recommendations this year
- 27 patients had no recommendations this year, but have had action taken since last year
- 30 patients were not part of our patient list last year, but had no recommendations.
Final results:
A total of 47 (10%) medication interventions were implemented over the course of two audits as a result of reviewing kidney function. As part of the two audits, 452 medication reviews were completed.
113 patients (25%) reviewed over two audits had recommendations made on their clinical journal to be used for future medication reviews in order to reduce inappropriate future prescribing, and to act as a prompt to future reviewing clinicians (Table 14).
Table 13. Medications with implemented changes across the two audits
| Medication Intervention | Count |
|---|---|
| Rivaroxaban | 8 |
| Ramipril | 6 |
| Allopurinol | 5 |
| Simvastatin | 5 |
| Alendronic Acid | 2 |
| Fenofibrate | 2 |
| Mirtazapine | 2 |
| Alogliptin | 1 |
| Apixaban | 1 |
| Bendroflumethiazide | 1 |
| Bezafibrate | 1 |
| Co-tenidone | 1 |
| Codeine | 1 |
| Enalapril | 1 |
| Lisinopril | 1 |
| Losartan | 1 |
| Metformin | 1 |
| Methotrexate | 1 |
| Pravastatin | 1 |
| Propranolol | 1 |
| Ranitidine | 1 |
| Rosuvastatin | 1 |
| Solifenacin | 1 |
| Tolterodine | 1 |
Table 14. Medication optimisation suggestions in the event of decline in kidney function over the two audits
| Medication | Number of suggestions | Medication | Number of suggestions |
|---|---|---|---|
| Statins | 20 | Irbesartan | 2 |
| Ramipril | 19 | Lansoprazole | 2 |
| Bendroflumethiazide | 12 | Moxonidine | 2 |
| Rivaroxaban | 9 | Perindopril | 2 |
| Furosemide | 8 | Pregabalin | 2 |
| Allopurinol | 7 | Rosuvastatin | 2 |
| Mirtazapine | 7 | Solifenacin | 2 |
| Simvastatin | 7 | Azathioprine | 1 |
| Lercanidipine | 6 | Bicalutamide | 1 |
| Metformin | 6 | Co-amilozide | 1 |
| Telmisartan | 6 | Co-dydramol | 1 |
| Butec | 4 | DHC | 1 |
| Empagliflozin | 4 | Enalapril | 1 |
| ISMN | 4 | Esomeprazole | 1 |
| Lisinopril | 4 | Ibuprofen | 1 |
| Propranolol | 4 | Imipramine | 1 |
| Alendronic Acid | 3 | Methotrexate | 1 |
| Alogliptin | 3 | Metoclopramide | 1 |
| Codeine | 3 | Nitrazepam | 1 |
| Gliptin | 3 | Nitrofurantoin | 1 |
| Losartan | 3 | Olanzapine | 1 |
| Quinine | 3 | Oxybutynin | 1 |
| Apixaban | 2 | Paracetamol | 1 |
| Ciprofibrate | 2 | Ranitidine | 1 |
| Dapagliflozin | 2 | Rivastigmine | 1 |
| Digoxin | 2 | Spironolactone | 1 |
| Diltiazem | 2 | Telmisartan/HCL | 1 |
| Fentanyl patch | 2 | Tolterodine | 1 |
| Fibrate | 2 | Tramadol | 1 |
| Gabapentin | 2 | Verapamil | 1 |
| Hydralazine | 2 | Zopiclone | 1 |
The findings were shared with clinical colleagues in the practice, including GPs and non-medical prescribers who are involved in suggestion and review of medications.
Further improvements for future audits:
- Time constraints did not allow for code relevance to be checked, meaning a patient is coded with CKD, but their current kidney function is not consistent with this. A separate piece of work could be completed in order to ensure coding is up to date and accurate in this cohort
- Capacity was a factor in ensuring timely completion of the audits. The reviews were completed alongside the day-to-day surgery workload, and it took longer to complete the repeat audit than the initial audit This may have meant that terms used and result collection methods may have varied, despite being completed by the same person. A framework of terms and a result recording template would be useful in future audits
- CrCl should be noted as well as eGFR on the data collection spreadsheet, as some medications (DOACs) and patients aged over 75 should have doses calculated based on this. It may be useful to note:
- If the patient is under nephrology
- Acute drug prescribing
- Hospital admissions
- Recent medication reviews.
Conclusion
Key areas of prescribing where greater care can be taken for patients with poorer renal function have been highlighted by this audit. In patients with CKD 3-5, medications are likely to need regular review to avoid prescribing inappropriate doses and avoid efficacy or safety implications.
These areas can be shared within the GP surgery, but also on a wider scale to improve day to day prescribing practice. Initial findings were presented at a clinical meeting held at the practice, and future learnings and repeat audits will be discussed on a regular basis. Areas highlighted through this project have shown care is required when prescribing DOACs, and other commonly used medications which advise use of a reduced dose in impaired renal function (statins, ACE inhibitors).
In patients with poor or declining renal function, it is important for them to be aware of the impact medication use can have on this, especially if already compromised. By discussing with patients that regular review and medication interventions may be required, this helps to create a culture of patient responsibility for their health, and encourages them to be curious about the indications for their medications. Patients should also be aware of the fact that this principle will apply to over the counter and herbal medications as well.
It is vital to encourage regular blood monitoring in order to have access to up-to-date, consistent readings of kidney function. In order to ensure doses are reviewed at the soonest possible opportunity, medication could be reviewed on receipt of blood test results, however, capacity to do this may be limited.
By conducting this review in a climate of a changing role from non-prescriber to non-medical prescriber, it was possible to see the impact the role of an NMP can have on streamlining patient care, and that immediate benefits can be seen. Whether this be noticed through fewer side effects, reduced medication or tablet burden or just by being better informed about the medication the patient takes, it helps to improve confidence for the prescriber in making these changes which have such as positive impact on short-term and long-term patient health outcomes. This also promotes the use of wider roles within primary care and can build greater public confidence in these, as well as reducing GP workload as well as allowing NMPs to be used to their full potential.
In order for further information to be gained to build a wider practice picture, this audit should be repeated. This will not completely eliminate error, but it can help to keep clinicians up to date with prescribing for patients with impaired renal function, as trends may vary over time and according to updated medication guidance. Completing a further audit as an NMP would also allow for longer term review of the impact of this versus a non-prescriber.