Respiratory Pharmacy & the Ward Pharmacist experience

1. Respiratory Pharmacy & the Ward Pharmacist experience by Abdol Malek bin Abd Aziz, MSc Clinical Pharmacy Conference , Port Dickson, 9-11 Jan 2003

2. Respiratory pharmacy • Emphasis on pharmaceutical care of respiratory patients plus • Other conditions that the patient is concurrently suffering

3. Respiratory Pharmacy • Covers: • Asthma • COPD • Idiopathic interstitial lung disease • Pleural disorders • Pneumonia • Drug-induced pulmonary disease

4. NHMS 1996 - Findings • High percentage (62.4%) not on inhalers • Mild asthmatics: 65.3% • Moderate : 52.1% • Severe : 23.7%

5. Compliance / adherence • Generally non-compliance rate ~ 50% (out patients) • 56% in Melaka (1999)* • Leads to hospital admission • 51.7% in Hospital Melaka ** • 13.3% were asthmatics (6/45 patients) • Non-compliance to inhaled medications: 50% (McGann & Elizabeth. Am J Nursing 1999) • Aziz AMA, Ibrahim MIM. Med J Malaysia 1999. • ** Aziz AMA, Senthil N, Jenny W. J Pharm Sci. 2003 (in press)

6. Some avenues to patient care… • Patients with allergic rhinitis often experience symptoms of asthma (Linneburg. Allergy 2002,57) • Allergic rhinitis preceded or developed at the same time as allergic asthma • Tx of allergic rhinitis reduced asthmatic symptoms or reduce risk of asthma

7. Inhaler technique • “good” rating ranged from 5-86% using MDIs • Technique improved after proper training* • 37.5% of pharmacy staff & 45.4% (15/33) outpatients having good technique€ €Inhaler technique survey among pharmacy staff and patients at the specialists clinic pharmacy, Hospital Melaka. Abstract of the Konferens R&D Farmasi, Kota Bharu 2002. * Cochrane MG, Bala MV, Downs KE et al. Inhaled corticosteroids for asthma therapy: patient compliance, devices , and inhalation technique. Chest 2000;117(2):542-550

8. Lung deposition of medication • Terbutaline: MDI – 8%, DPI – 22%* • Effect of spacer device: Lung deposition increase from 9 to 21% Oropharynx deposition reduced from 81 to 17%# * Borgstrom L, Derom E, Stahl E, et al. The inhalation device influences lung deposition and bronchodilating effect of terbutaline. Am J Respir Care Med 1996;153:1636-1640. #Newman SP, Millar AB, Lennard-Jones TR et al. improvement of pressurised aerosol deposition with Nebuhaler spacer device. Thorax 1984;39:936-941.

10. Bronchial asthma • Defn: Reversible airways obstruction , airway inflammation, airways hyperreactivity to a variety of stimuli • Incidence: 3-6% in Australia, 4.2% in Malaysia* , 2-5% in Africa • Symptoms: Wheezing, dyspnoea, chest tightness, cough * National Health and Morbidity Survey Vol. 11, Public Health Institute. 1996

11. Asthma in children Children: • Dry powder inhalers has greater systemic effects than MDIs§ • Pharmacists: recommend MDI with spacer device for children. § Kereem E . Ann Allergy Asthma International 2002;89.

12. Pharmacist’s roles • As educator and support person • Counsel on role of each medication • Difference between preventer – reliever • Emphasise safety of inhaled c’steroids • Discuss adverse effects – ways to minimise • Check and correct proper use of inhalers • Encourage use of spacers and peak fl. meters

13. Pharmacist’s roles • Check compliance – 56% noncompliance rate1 • Check usage of medications for other illnesses, OTC products, GP’s drugs, etc • Dispels myths about asthma and inhaler use • Encourage asthma action plan AMA Aziz, MIM Ibrahim. Medication noncompliance - a thriving problem. Med J Malaysia 1999;54:192-5.

14. Objective • To have an influence on prescribing and related clinical practice

15. How to start? • Ward pharmacy • then • Respiratory pharmacy

16. Ward pharmacy • Back to basics • Supplies, inventory, pricing, • Dosage, category of drug in MOH list • List A, std item • Synergistic activity with in-patient pharmacist/satellite pharmacist

17. At the ward… • Familiarise with the ward- acquaint with ward staff ie. sister & nurses • Ward procedures • Own reading on common drugs used • develop confidence

18. Ward rounds • Consultant’s rounds: already have a high level of interest in optimising drug therapy • Vigilant on ADR and side effects

19. Preparation before rounds • Very, very important • May take an hour or more initially Objective: • to anticipate areas where information is likely to be requested • To identify topics for discussion

20. Becoming prepared provides… Confidence

21. Clerking • Same as any other pt • Biodata, diagnosis, investigations, lab results, x-rays, etc, • Document using card or form • Monitor, • Identify drug-related problems or issues • Plan for solution - check-up - talk to Dr or specialist, nurse

22. Things to do… • Estimate creatinine clearance ClCr if the serum creatinine is >150µmol/l in adults less than 70 yrs using Cockcroft and Gault equation • Abnormal levels of urea or albumin may alter the disposition of some drugs

23. Patient parameters • Pt. with liver disease – elevated liver function tests • Severe cardiac failure may affect both renal and hepatic clearance of drugs may necessitate dose individualisation • Calculate predicted blood levels if therapeutic monitoring of a drug is required

24. Attending ward rounds • Be PUNCTUAL • Degree of involvement and pharmacist’s role depend on the leading physician • Doctors may undertake management or teaching role or both • They may not ask for pharmacist’s comments

25. Adequate preparation Being tactful, yet assertive prioritise Regular attendance Present info on a problem concisely Provide adequate follow up A successful attendance in ward rounds

26. Pharmacist’s comments • Unlikely to be a personal insult and no offence should be taken • The advice may be used on a similar pt in future • Occasionally it may be used by the consultant against his junior staff – communicate with the houseman to avoid unnecessary embarrassment • Follow up on pts where comments have been accepted ie. supplies and instructions on usage

27. Specialisation • Collins English Dictionary and Thesaurus: defines special as ‘distinguished’ or ‘set apart from’ • Specialisation ~ characteristics that distinguish a clinical pharmacist from other pharmacists • Obtained thru’ further education and training

28. Nursing profession development • Shift in promotion ladder * • Dual career pathway • management ☞sister – matron • Clinical nurse ☞ advanced practice nurse (same ranking as sister/tutor) • Similar to UK and Canada situation *Nafsiah Shamsudin. Specialisation of the clinical nurse in the Malaysian setting. Sept. 2000.

29. Specialisation • Extra qualifications preferable • Sometimes not necessary • MSc, MPharm • PhD • Experience, confidence, way of thinking, networking, research-oriented, etc

30. Specific situations • Asthma • Counselling • Pharmacoherapy issues ie. Drug of choice: β-2 agonists (short-acting, long-acting, corticosteroids (inhaled , oral), • Drug forms: inhalers, oral tablets, nebs

31. Other roles • Conformance to guidelines: MTS, GINA • Research: eg. • drug use • clinical trials on outcomes of pharmacist-treated pt vs non-pharmacist pts, counselled vs non-counselled • Inhaler technique – relate to outcomes • Asthma clinic – check peak flow, compliance to tx, appointments for counselling, etc

32. What others have achieved… • Pediatric asthma management programme Covenant Health System, Texas, US ± • Found many asthma pts admitted for various reasons ie. Lack of medication, non-compliance, improper inhaler technique • Remedy: face-to-face counselling. Pharmacists counselled pts and families • Complete pt information leaflets given, videotapes • Spent 30-60 mins per pt ±Razia M, Gordon H. Am J Health-Syst Pharm 2002;59. p. 1829.

33. results • 69 pt counselled: 106 vs 51 ER visits or admissions pre and post counselling (↓52%) • Cost avoidance: USD126,500/= → Counselling beneficial and reduces admission rates.

34. COPD

35. C.O.P.D.-X Plan • C = Confirm diagnosis, severity, complications • O = Optimise patient function (impairment, disability and handicap) • P = Prevent deterioration • D = Develop self-monitoring and self-management care plan • X = guide for managing exacerbations

36. C….confirm... • Exclude asthma, cardiac disease etc • Assess severity • Assess reversible components • Identify complications and co-existing conditions • history, examination, spirometry, xray chest, FBE

37. O….optimise…. • Smoking cessation • Optimise drugs • safe and effective - don’t over-prescribe • Treat complications • Optimise psychosocial issues • Optimise nutrition (consider dietician) • Encourage exercise (consider physio gym) • Pulmonary rehabilitation • Lung reduction surgery or transplantation

38. P….prevent…. • Smoking cessation (help and monitor) • AAAAA • Occupation and other dusts • Stop unhelpful drugs • Prevent infections • influenza vaccination (?Pneumococcal) • relevant antibiotics for purulent sputum and fever • Pulmonary Rehabilitation • Transplantation

39. P….prevent…. • Check for complications & concurrent conditions • osteoporosis, depression, cor pulmonale, OSA/hypoventilation • Consider oxygen if hypoxaemic • Regular review • lung function

40. D….discuss, develop…. • Educate patient and carers • Pulmonary Rehabilitation and Patient Support Groups • Assess self-management capacity • Develop a collaborative care plan • monitor to identify exacerbations early • how to self-initiate treatment • what to do in an emergency

41. X… Exacerbations • Inhaled bronchodilators and systemic glucocortocoids are effective treatments for acute exacerbations (Evidence A) • Patients with clinical signs of infection(change in sputum colour and/or fever, leucocytosis) benefit from antibiotics (Evidence A)

42. Asthma Action Plan • Designed for pts with asthma to: ^ recognise deterioration and ^ respond appropriately • Action Plan will prevent ^ delay of initiation of preventer dose increases ^ prolonged exacerbation ^ adverse effects on pts life

43. Peak Flow Monitoring • Peak Expiratory Flow (PEF) – the greatest flow velocity which can be generated during a forced expiration starting with fully inflated lungs • Simple, quantitative, reproducible measure of airway obstruction • Meters are cheap, lightweight and portable • Repeated measures highly reproducible with each individual patient, if the same meter is used

44. Peak Flow Monitoring • Actual number not important, but the trend is • Measures response to bronchodilator therapy – increase by 20% post treatment (provided the baseline reading > 300ml/min adults) • Measures early deterioration before pt. feels the change in his disease {diabetics monitor blood sugar, asthmatics measure lung function…}

45. Pulmonary Rehabilitation Program • Established in the Repatriation General Hospital, Adelaide since many yrs ago • A structured program using weekly lectures spanning over 3 months • 2 hrs session (1 hr lecture each person ) @1.30pm • Coordinated by the Resp. Rehab. Clinic • Pharmacist • Talked about “Medications and Airways Disease”

46. PRP team • Respiratory physician (Chairman), • Technical officer, Respiratory Function Unit • Clinical Nurse Consultant, Respiratory Rehab Clinic • Clinical Pharmacist • Physiotherapist • Rehabilitation Counsellor • Dietician • Occupational therapist