UK
Clinical Pharmacy
Association
UK
Clinical Pharmacy
Association
Co-prescribing of long-acting muscarinic antagonists (LAMA) and short-acting-muscarinic antagonists (SAMA) are discouraged due to the potential exacerbation of anticholinergic side effects. This audit was initiated after discovering frequent co-prescriptions at a large teaching NHS Trust, underscoring a critical need for intervention. The Trust initiated several strategic interventions, including the implementation of an electronic prescribing and medicine administration (ePMA) alert system in May 2023, and targeted educational sessions for junior doctors in November 2023.
This audit assessed whether prescribing practices for LAMA and SAMA within the Trust align with the British National Formulary (BNF) and NICE Clinical Knowledge Summaries (CKS) guidelines. The audit also aimed to identify areas of poor prescribing and identify any anti-muscarinic side effects. Additionally, the audit evaluated the effectiveness of recent initiatives, including the ePMA alerts and educational interventions. The audit standard was 100% avoidance of co-prescribing LAMA and SAMA.
This retrospective audit, conducted from February 2023 to January 2024, targeted two respiratory wards and reviewed the medical records of 173 inpatients prescribed both LAMA-containing inhalers and SAMA (ipratropium) nebulisers. Data were collected from the Lorenzo system, supported by the ePMA team, and analysed using Excel. A subgroup of 31 patients was randomly selected to evaluate the impact of pharmacists in preventing co-prescriptions.
This two-cycle audit assessed pre- and post-intervention prescribing practices, with the implementation of ePMA alerts in May 2023 and junior doctor training in November 2023. The audit found a compliance rate of 34% (n=55/173) in avoiding LAMA and SAMA co-prescriptions, highlighting significant non-adherence to guidelines. Among 31 patients reviewed for pharmacist intervention, only 10% (n=3/31) avoided co-prescribing, underscoring the pharmacists’ crucial but limited impact.
Despite these interventions, the overall effect on prescribing practices was modest, reflecting the challenge of altering established behaviours. Notably, patients were not equally divided across pre- and post-alert implementation, which may have influenced the outcomes. The estimated annual cost of co-prescribing was £4,870.53, a modest sum that points to unnecessary financial waste.
No antimuscarinic side effects were reported in the reviewed patient group (n=0/10), indicating maintained patient safety. However, the persistence of co-prescriptions underscores the need for enhanced strategies. A re-audit in July 2025 will reassess compliance, with further interventions planned if adherence remains insufficient. Further improvement may be achieved through a Quality Improvement project.
The audit revealed progress in reducing the co-prescription of LAMA and SAMA medications, though compliance with BNF and CKS guidelines remains below the desired standard. The interventions, including ePMA alerts and targeted training, showed some positive impact but are not yet sufficient to fully align prescribing practices with national standards. The absence of reported antimuscarinic side effects indicates that patient safety has been maintained despite ongoing challenges.
Moving forward, a re-audit in July 2025 is planned, with a focus on refining and expanding strategies. Incorporating a QI project may further enhance compliance and ensure that prescribing practices meet the highest standards of care.
This study did not require ethics approval and was approved by the Trust Clinical Effectiveness team.
Additional authors: Stephanie Bell, Nasir Akthar
The opinions expressed in this article are those of the author. They do not purport to reflect the opinions or views of the UKCPA or its members. We encourage readers to follow links and references to primary research papers and guidance.
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