Katie Joyce and colleagues describe how their hospital pharmacy team in the north of England worked collaboratively across the primary-secondary care interface to implement shared care agreements for a cohort of 270 patients prescribed amiodarone to optimise the patient experience, overcome operational challenges and streamline processes.
Amiodarone is a class III antiarrhythmic drug used both in the acute and long-term management of cardiac rhythm disorders. It is highly effective in maintaining sinus rhythm and remains widely utilised in clinical practice owing to its broad-spectrum activity.1.
Long-term treatment with amiodarone is indicated in managing recurrent tachyarrhythmias, including supraventricular and ventricular tachycardias (VT). In persistent or permanent atrial fibrillation (AF), rate control is often adequate to improve symptoms. Benefits of this approach include ease of initiation, lower risk of iatrogenic adverse effects and reduced hospital admissions related to AF.2
The National Institute for Health and Care Excellence (NICE) recommends explicitly against using amiodarone due to the lack of evidence on efficacy as a rate control strategy, in addition to the risk of severe and potentially irreversible side effects with long-term use.3
Caution in prescribing
Previously, in County Durham and Darlington, amiodarone could be initiated by primary care clinicians on the advice of a specialist. However, in 2023, following the introduction of the integrated care system (ICS), the three local drug formularies across Northeast and North Cumbria (NENC) were merged into a single ICS-wide formulary, with amiodarone allocated an ‘amber’ shared care status.
This move corroborated adding amiodarone to the primary care ‘do not initiate’ list. Consequently, the ‘amiodarone for patients within adult services’ shared care protocol was published by the NENC Medicines Subcommittee in February 2024.
NHS England guidance recommends that existing patients taking amiodarone in primary care should be reviewed to ensure prescribing remains safe and appropriate and that a shared care agreement is introduced.4
CDDFT and shared care agreements
In June 2024, NHS England highlighted the importance of teams working together across the primary-secondary care interface to meet the pressures and demands of both settings under the direction of the integrated care board (ICB) – something that has shown great success in this region.
The NENC ICB medicines optimisation team worked with the County Durham and Darlington Foundation Trust (CDDFT) pharmacists to drive engagement within primary and secondary care to identify and address a cohort of patients taking amiodarone without a shared care agreement in place.
Working with GPs and consultant cardiologists across the interface, a work plan was created to share resources, maximise efficiency and optimise patient experience. An audit tool was designed to capture all patients currently prescribed amiodarone in the 61 GP practices across County Durham.
The audit tool was completed by pharmacists and pharmacy technicians employed within primary care networks (PCN), minimising the impact on GP time. Data collection included drug indication (if known), prescribing history, evidence of an existing shared care agreement and compliance with monitoring recommendations.
The CDDFT pharmacy team was then commissioned to act upon the audit findings. Two senior cardiology clinical pharmacists reviewed the data, triaging patients according to indication: those who required monitoring to be completed, those who required consultant review and those who could potentially stop treatment.
Discontinuation was considered for patients historically initiated on amiodarone first-line for persistent or permanent AF or those previously treated for paroxysmal AF who had since progressed to permanent AF. Table 1 shows audit figures by indication for a total of 93 patients who required a new shared care agreement.
Table 1. Indications for amiodarone
*Of a total of 93 patients who required a new shared care agreement
Ensuring safety and efficacy of amiodarone
It was noted that in undertaking the review process, there was a risk that amiodarone would be inadvertently stopped in a patient with a ventricular arrhythmia – a condition with a significant risk of sudden cardiac arrest if left uncontrolled.
The high-risk nature of amiodarone and the conditions it treats make it essential that professionals with expertise in cardiology and the safety and efficacy of medicines undertake this work. While due diligence was taken to minimise deprescribing risk, it was acknowledged that there are also significant risks with continuing amiodarone long-term unnecessarily in a cohort of AF patients.
The extensive side effect profile of amiodarone is well established. The estimated prevalence of treatment-related adverse effects rises from 15% in the first year to 50% with prolonged administration. It is estimated that around 20% of patients require discontinuation of therapy due to hepatotoxicity, pulmonary toxicity or altered thyroid function.5
Many of the adverse effects (Table 2) are treatable, especially if detected early, and may be fully or partially reversible following discontinuation or dose reduction.
Table 2. Summary of common amiodarone adverse effects6-8
Given significant safety concerns, clinical guidelines and existing shared care protocols stipulate robust monitoring requirements for amiodarone across the primary-secondary care interface, including biannual thyroid and liver function tests and annual electrocardiogram checks.
Audit and monitoring of amiodarone
The audit, which returned data for 129 patients, found that 21% of patients were not receiving all the recommended monitoring. However, where a shared care agreement was already in place, 100% were being monitored correctly. It may, therefore, be anticipated that when a shared care agreement is in place, patient safety and experience are improved through more timely detection and avoidance of adverse events.
The CDDFT cardiology pharmacists liaised directly with PCN staff to resolve queries and to provide advice as required. They completed the details of the shared care agreement paperwork, giving background and clinical information that would support the 11 cardiologists across CDDFT in reviewing the safety and efficacy of amiodarone prescribing across the region.
A key benefit of the approach was avoiding the ‘advice and guidance’ referral system for repatriating patients from primary care into secondary care. This would have taken GP time to complete the referrals and created a backlog of referrals for secondary care to respond to, in which answers to queries not relating to missing shared care agreements could have been unduly delayed.
Barriers and benefits
The primary barrier to this work was engagement, with only 40 of 61 GP practices (66%) in the region returning audit data. For participating practices, assurances have been provided that prescribing is appropriate for those who are to continue amiodarone, and a number of patients are anticipated to stop treatment after all consultant reviews have taken place, thus reducing the monitoring and prescribing burden on the practices.
This process has been completed through pharmacy networks, minimising the impact on workload for primary and secondary care clinicians.
Including this audit in the ICB medicine optimisation work plan ensured practices were supported with resources to complete data collection. A further challenge was access to historical medical records and subsequent time taken to ascertain indications for amiodarone.
Patient experience is significantly optimised by minimising adverse events, stopping treatment that is no longer clinically indicated and triaging patients before sending correspondence directly from secondary care.
Throughout this work, the pharmacy teams worked to minimise the impact on clinician workload in primary and secondary care. This may be considered particularly important given the increasing demands on resources and rising tensions around shared care prescribing.
Conclusion
This case study provides an example of the ICB successfully acting as a bridge between care settings to improve patient care and experience, overcome operational challenges and streamline processes.
This work involved building relationships across the primary-secondary care interface and can provide a model for sustainable collaboration on future shared care work.
The NENC ICB medicines optimisation team commented: ‘Working collaboratively with secondary care pharmacy colleagues to support the review of patients prescribed amiodarone across County Durham has benefited all parties involved. There has been timely identification and review of patients, minimal impact on primary care capacity and minimal disruption to patients accessing medication.’
Dr Darragh Twomey, consultant electrophysiologist at CDDFT, also observed: ‘This approach streamlined a substantial amount of work. It ensured that the shared care agreements were directed to the appropriate consultant with a summary of the clinical presentation requiring amiodarone therapy. It dramatically reduced the time for medical staff to complete the process.’
Authors
Katie Joyce MPharm PGDip
Lead pharmacist for medicine and community services
Fraser Stewart MPharm MSc
Senior clinical pharmacist
Daniel Jukes MPharm Msc
Senior clinical pharmacist
All of County Durham and Darlington NHS Foundation Trust, UK
References
1 Gupta D et al. Atrial fibrillation: better symptom control with rate and rhythm management. Lancet Reg Health Eur 2024;32:100801.
2 Van Gelder IC et al. Rate control in atrial fibrillation. Lancet 2016;388:818–28.
3 National Institute for Health and Care Excellence. Atrial fibrillation: diagnosis and management. NICE guideline NG196; 2021 (accessed September 2024).
4 NHS England. Items which should not routinely be prescribed in primary care: policy guidance. NHS England 2023 (accessed September 2024).
5 Merino J et al. Treatment with amiodarone: how to avoid complications. eJ Cardiol Pract 2011;10(2).
6 Ennogen Pharma Ltd. Amiodarone Hydrochloride 200mg Tablets. Summary of Product Characteristics (accessed September 2024).
7 Wolkove N, Baltzan M. Amiodarone Pulmonary Toxicity. Can Resp J 2009;16:43–8.
8 Wang AG, Cheng HC. Amiodarone-Associated Optic Neuropathy: Clinical Review. Neuro-ophthalmology 2016;41(2):55–8.
