Medicine management – session 2 Advising patients about medication and drug monitoring

1. Medicine management – session 2Advising patients about medication and drug monitoring Dr Ally Duncan Education Fellow and Anaesthetic Registrar

2. Last time we covered Prescribing should be a positive decision sometimes it is not appropriate (e.g. ethical or cost-benefit reasons or because other professionals may have more experience) Where to get advice What patients need to be told You are responsible for your prescriptions

3. This week we will cover • Drugs which require monitoring • Sharing risk with patients • Discussing concordance and adherence

4. Case 1 Fred Jones 75 year old retired businessman Presented to ED 2 days ago with palpitations Self-discharged before receiving treatment Returns to his GP because of on-going palpitations

5. Case 1 No history of chest pain or breathlessness No past medical history of note He takes no medication and has no allergies Smokes 20/day, drinks 50 units/week and takes no drugs

6. On examination: • Pulse 70 bpm (irregularly irregular) • BP 170/100 • RR 14 • SpO2 97% on air • Heart sounds normal • Chest clear • Luckily, your practice has an ECG machine…

7. Fred’s ECG

8. Fred’s ECG

9. What do you do next? How do we assess Fred’s risk of stroke? What are the options for long-term anticoagulation? How do we quantify the risks and benefits of each? How do we explain this to the patient?

10. Risk Stratification High risk of stroke: Previous ischaemic stroke/TIA or thromboembolic event >75 years with risk factors Clinical evidence of valve disease or heart failure, or impaired LVF on echocardiography Moderate risk of stroke: >65 years of age without risk factors <75 years of age with risk factors Low risk of stroke: < 65 years of age without risk factors

11. Annual risk of stroke

12. CHADS2 score • Congestive heart failure = 1 • Hypertension (or treated hypertension) = 1 • Age > 75 years = 1 • Diabetes mellitus = 1 • Previousstroke or TIA = 2 • NICE guidelines recommend: • Aspirin if the total score is 0 or 1 • Warfarin (if there’s no contraindications) if the total score is ≥2

13. We decide to prescribe warfarin • What risk factors must we consider?

14. Factors that increase the likelihood of bleeding > 75 years of age Use of antiplatelet drugs Use of NSAIDs Polypharmacy Uncontrolled hypertension History of bleeding Poorly controlled anticoagulation therapy

15. Prescribing warfarin • How are you going to decide what dose of warfarin to prescribe? • How often will Mr Jones’s INR need to be monitored? • Should LMWH be given in conjunction with warfarin?

16. Prescribing warfarin • What information should Fred be given? • What is Fred was Fredarika and thinking of becoming pregnant?

17. Prescribing warfarin

18. Sample warfarin chart

19. WarfarinOSCE station • Devise a marking scheme for an OSCE station, which examines the student’s counselling skills

20. The introduction Consenting the patient Wash hands Introduce yourself Check name, DOB Consent to procedure Confidentiality statement Look for clues • What do they already know? • Nature and causes of AF • Risks of AF • Changes in the history? • CI to anticoagulation?

21. Discuss anticoagulation Patient information • Why anticoagulation? • Why warfarin ? • How does it work? • Risk v Benefit When and how to take (dose, frequency, timing) Compliance Monitoring and target INR Drug interactions Advice regarding surgery etc

22. Follow-up • “Yellow book” • Colours of tabs • Brown • Blue • Pink • Allow time for questions

23. You may be asked to consent a patient for a procedure or to commence a medication • Try to develop a framework of how you will approach this in an OSCE situation • Developing OSCE questions and model answers helps you develop your technique

24. CASE 2 • Esther Baruch • 59 years old • 4 month history of pain in her RIGHT knee • Clinically and radiologically she has mild OA • Current meds: paracetamol 1g prn bendroflumethiazide 2.5mg od • Not taking any OTC medications • Used to take ibuprofen but stopped when neighbour said they could cause ulcers

25. What management options are available • What non-pharmacological approaches might you advise?

26. The analgesic ladder

28. Esther Baruch 12 Green Street Manchester M20 1AB 01/01/xx Co-codamol 30/500 tablets Two tablets to be taken four times a day for pain relief Supply 200 tablets ----------------------------------- Ibuprofen 400mg tablets One tablet to be taken three times a day for pain relief supply 84 tablets ----------------------------------- Omeprazole 20mg capsules One to be taken in the morning to protect your stomach supply 30 tablets A Doctor xx/xx/xx

29. Esther Baruch 12 Green Street Manchester M20 1AB 01/01/xx Senna 7.5mg tablets Take two at night to prevent constipation Supply 56 tablets A Doctor xx/xx/xx

30. Case 3 • Faizel Iqbal • 48 years old • Presents with a 3 day h/o red, swollen and tender 1st Left MTP joint • PMH: recurrent gout • 6 episodes in the last 18 months • He has been on allopurinol 300mg od for 3 years

31. What are your immediate management options? Why is he still getting flare-ups? What other issues should you consider?

32. Faizel Iqbal 10 Green Street Manchester M20 1AB 01/01/xx Naproxen 250mg tablets Take 3 tablets straight away, then take one tablet every eight hours until your gout has settled Supply 56 tablets ----------------------------------- A Doctor xx/xx/xx

33. Drug Interactions INDUCERS • Phenytoin • Carbamazepine • Barbiturate • Rifampicin • Alcohol (chronic) • Sulphonylureas INHIBITORS • Omeprazole • Disulfram • Erythromycin • Valproate • Isoniazid • Cimetidine • Ethanol (acute) • Sulphoamides

34. Summary We’ve talked about risk stratification regarding AF and stroke We’ve discussed the importance of drug compliance and drug monitoring We’ve highlighted the problems that misinformation can create