NSAID Regional Audit 2012
Please complete one form per patient treated with NSAIDs or COX-2 Inhibitors between 29th October and 7thDecember 2012 and return to Ruth Clark, Pharmacist at Marie Curie Hospice Liverpool, Speke Road, Woolton, Liverpool, L25 8QA; via email or via fax on 0151 801 1458.
1. ICN:
Aintree Halton Isle of Man Liverpool St Helens & Knowsley
Western Cheshire West Lancs, Southport and Formby Wirral Warrington
2. Setting:
SPC Inpatient Hospital Home Outpatient
Patient Details:
3. Sex:MaleFemale
4. Age:<40yrs 40-54yrs 55-64yrs 65-74yrs >75yrs
5. Diagnosis:
NSAID Treatment:
6. Indication for starting an NSAID/COX-2 inhibitor:
Bone Pain Visceral Pain
Neuropathic PainInflammatory Pain
Unknown
Other (please specify)
7. Which NSAID is prescribed?
Ibuprofen poDiclofenac prDiclofenac po
Nabumetone poNaproxen poPiroxicam melt po
Etoricoxib poCelecoxib poEtodolac po
Ketorolac sc
Other (please specify with route)
8. What dose is prescribed?
9. Is this the first NSAID/COX-2 inhibitor to be prescribed?
YesUnknown
No (please specify others tried) Tried
10. How long has the patient been on this NSAID/COX-2 Inhibitor?
Newly startedLess than 1 week
Between 1 week and 1 monthBetween 1 month and 6 months
Between 6 months and 1 yearMore than 1 year
Unknown
11. Who initially prescribed this NSAID/COX-2 inhibitor?
GPPalliative Care Team (Community)
Hospital Specialist Palliative Care TeamPalliative Care Team (Hospice setting)
Hospital Team(non Palliative Care)Pain Specialist (Anaesthetist/Chronic Pain Team)
UnknownOther(please Specify)
12. Does the patient have a history of? (tick all that apply)
Ischaemic Heart DiseasePeripheral Arterial Disease
Cerebrovascular diseasePeptic Ulcer Disease
Renal impairment (please specify eGFR) eGFRml/min
13. What concurrent analgesics is the patient prescribed? (tick all that apply)
ParacetamolCodeine Tramadol
MorphineOxycodonePregabalin
GabapentinTopical NSAID
Other (please specify)
14. What concurrent medication is the patient prescribed? (tick all that apply)
SSRIMirtazapineSteroidLMWH
AspirinClopidogrelWarfarin
Other anticoagulation drug (please specify)
Other medication increasing risk of bleeding (please specify)
15. Does the patient have any other cautions/precautions for treatment with NSAIDs/COX2 Inhibitors? (e.g. low platelets)
No Yes (please specify)
16. Are any gastro-protective agents prescribed? (please tick all that apply)
LansoprazoleOmeprazole
PantoprazoleRanitidine
EsomeprazoleMisoprostol
Other (please specify)
17. What dose of gastro-protective agent was prescribed (if applicable)?
18. If no gastro-protective agent is prescribed, why not?
Unable to swallowLow GI risk Dying phase
Other (please specify)
19. Was renal function checked prior to commencing an NSAID/COX-2 Inhibitor?
Yes (please specify eGFR if known)eGFR ml/min
NoAdmitted on treatmentUnknown
20. When was renal function checked after commencement of NSAID/COX-2 Inhibitor?
1-3 days 4-7 days 8-14 days >14days Not checked
Admitted on treatmentUnknown
21.If newly initiated, when was treatment reviewed after commencement?
1-3 days 4-7 days 8-14 days >14days Admitted on treatmentUnknown
22. Was treatment continued, and why?
Yes – full relief of painNo – no relief from pain
Yes – partial relief of painNo – alternative NSAID to be tried
No – renal function declinedNo – bleeding
No – gastric side effects
Yes – other reason (please specify)
No – other reason (please specify)