Paracetamol is a commonly used first line analgesic. The BNF includes a warning that patients with a body weight under 50kg and those with risk factors for hepatotoxicity may be at risk of harm from therapeutic doses, advising that clinical judgement is used to adjust the dose in such patients. There is currently no national standard prescribing guidance for paracetamol in these patient groups, although evidence suggests that a reduced dose of paracetamol may achieve therapeutic effects and have a reduced risk of hepatotoxicity for patients at risk.
A report by the Healthcare Safety Investigation Branch (HSIB) highlighted the case of an 82-year-old patient weighing 40.5kg who received the maximum oral dose of paracetamol during a hospital admission. The patient sadly died during the admission, with the coroner listing paracetamol-induced hepatotoxicity as one of the direct causes of death.
To address this patient safety concern in the population of care home residents in Cheshire, this project aims to reduce the risk of hepatotoxicity in frail elderly care home residents with a body of less than 50kg who are prescribed paracetamol, whilst maintaining effective analgesia.
An EMIS search was created to identify all care home residents with a body weight below 50kg who are prescribed oral paracetamol. Patients identified using the search received a person-centred review focusing on paracetamol use with a Medicines Optimisation in Care Homes (MOCH) pharmacist. Dose recommendations were based on the British Hepatology Pharmacy Group (BHPG) position statement on oral paracetamol dosing in low weight. Residents who were commenced on a reduced dose were followed up within two weeks to ensure ongoing effective analgesia.
The project has been delivered in six care homes across one PCN in Cheshire, with the positive outcome that all residents who had the dose of paracetamol reduced were happy to continue at the lower dose at the two-week follow up review. A prescribing alert is now embedded into the EMIS system to prompt prescribers to consider a reduced dose of paracetamol at the point of prescribing for care home residents who have a weight of less than 50kg. A poster for care homes has been developed to engage staff and invite feedback on the project.
