‘Sleep tight’ – a centralised system for melatonin prescribing

Abstract

Objective To describe our experience of developing a centralised system for the prescription of melatonin in children. Methods Melatonin is used widely to help initiate sleep in children. A recent randomised controlled trial demonstrated that melatonin brought sleep onset forward by an average of 20 min and prolonged sleep by an average of over 40 min.1 The cost of paediatric melatonin prescriptions in our Trust April – November 2010 was £231 236.38. (Extrapolated annual spend £462 472.76). As a part of our cost improvement processes, prescribing practices and charges were reviewed. The cost of melatonin to us from ‘community prescriptions’ (FP10) varied widely depending on the individual pharmacy charge, the formulation prescribed and brand of melatonin dispensed. There was no standard quality control process. Hospital pharmacists and clinicians produced a guideline for the prescription of melatonin in paediatric patients, rationalising the formulations and preparations available. Families were informed that melatonin would be prescribed only from the hospital pharmacy. Results Families have been very co-operative with the new procedures. Issues arose in the first few weeks due to a significant shortage of melatonin in stock relative to the amounts of melatonin being prescribed. One batch of melatonin 3 mg MR capsules (imported from the USA) contained 5.6 mg of melatonin. This product is not required to meet pharmacopeial standards and, unlike melatonin capsules supplied within UK, does not have an upper limit for actual value. Following discussion, the decision was made to stop using this product. Patients are managed on the standard release capsules and licensed 2 mg MR tablets (circadin) alone. Following implementation of inhouse melatonin dispensing the total spend on melatonin for January to March 2011 was £52 506.64. The predicted annual expenditure is therefore £210 026.56 (cost saving £252 446.20 per year). Conclusion The centralised prescribing of an unlicensed medication has rationalised prescribing practice and ensured quality control procedures. It has allowed the development of a database allowing easier monitoring and audit of prescribing and is projected to result in significant cost savings. Learning points from the process include the importance of Accurate estimation of the likely monthly demand – perhaps by auditing prescribing practice of all clinicians for one month prior to implementation in order to gain a baseline. Clear identification of each stage in the ‘prescription pathway’ – from the family requesting a prescription to collecting the medication. Proactive communication to all pharmacy staff about the reasons for change, so families are given consistent information. This experience is being used to inform the centralisation of prescribing of other ‘specials’ within our Trust and may be extrapolated to similar services within other Trusts.