Adherence to rifaximin initiation and prescribing within King’s College Hospital and transfer of prescribing to primary care
Authors: Monk G , Shah S 
Published: November 2023

Abstract

Introduction
Hepatic encephalopathy (HE) is described as ‘the most debilitating manifestation of liver disease, severely affecting the lives of patients and their caregivers’ due to cognitive manifestations1. In March 2015 NICE Technical Appraisals approved the use of rifaximin in hepatic encephalopathy2. Rifaximin must be initiated in secondary care under a consultant gastroenterologist or hepatologist. Once considered stable after an initial period of six months (or three months within South East London), prescribing and supply should move to primary care with appropriate Shared Care Agreement documentation.

Aim
An audit to establish the appropriate initiation and follow up of rifaximin in patients with HE at King College Hospital (KCH) in line with area prescribing was completed in 20173. The purpose of this re-audit is to compare results following implementation of the electronic initiation form, recruitment of a specialist pharmacy technician, and Shared Care Agreement adaptations.

Methods
Data was collected retrospectively between 1st January 2022 to 31st October 2022, from electronic patient records and dispensing records. Data was compiled and analysed using Microsoft Excel.
An ethics approval was not deemed necessary as we were looking retrospectively at standard practice.

Results
52 adult patients were identified and the results against the audit standards were as follows: All patients should have a documented diagnosis of HE– 90% was found; All patients should have been initiated directly or been advised by a consultant gastroenterologist or Hepatologist – 94% was found; 90% of patients should have documented evidence of improvement – 62% was found; All patients should receive the first 3-6 months of rifaximin from KCH – 81% was found; All patients should have a hepatology clinic appointment booked – 96%; was found; All stable patients should have shared care agreement in place – 77% was found; All patients should have the initiation form completed on EPR at the time of prescribing – 62% was found.

Discussion/Conclusion
Although no standards were met there were improvements in most objectives when the data was compared to the 2017 audit. Only 23% of stable patients compared to 50% in 2017 received more than a 6 month supply of rifaximin or did not have a shared care agreement in place. Recruitment of a specialist pharmacy technician could be attributed to this improvement, as they facilitated the whole pathway. Of the 38% of patients who did not have an initiation form completed, 4 were started as inpatients, but the remaining 16 patients were initiated in outpatient clinics. This highlights a need for outpatient clinicians to be reminded of the rifaximin initiation process. Limitations included different documentation styles per clinician reviewing patients and therefore reduction in HE symptoms caused by rifaximin may not have been documented resulting a lower outcome for standard 3. Following this re-audit a pathway to refer patients newly started on rifaximin to a pharmacist led general hepatology clinic will be established. This is to ensure effectiveness of rifaximin is consistently assessed, documented and referred to the pharmacy technician, who should be encouraged to lead on medicines management across sectors of care.

References
1. European Association for the Study of Liver guidelines on Hepatic Encephalopathy - Hepatic Encephalopathy in Chronic Liver Disease - EASL-The Home of Hepatology. 2014, volume 21, page 642-659
2. NICE TAG for Rifaximin - 1 Guidance | Rifaximin for preventing episodes of overt hepatic encephalopathy | Guidance | NICE. March 2015, reviewed 2018
3. Thompson, C & Shah, S. Adherence to rifaximin initiation and prescribing within King’s College Hospital (KCH) and transfer to primary care in accordance with the South East London Area Prescribing Committee Shared Care Agreement. Presented at UKCPA Annual Conference 2018.