Medicines Information

1. Medicines Information for future pharmacists February / March 2016

2. Overview of the Session • Receiving enquiries • Seeing the enquiry in context (background information etc.) • Searching for information • Common resources: their relative strengths and weaknesses • Communication skills • Giving/receiving queries (verbal v.s. written) • Ethical dilemmas

3. Background Information

4. Query #1 • A GP rings and asks you: “Are steroids safe in pregnancy?” • What additional information may be required in order for you to answer the query (or for you to refer the query to MI for answering)?

5. Query #1 • Who is calling? • Name, designation, contact details etc. • Patient specific or general? • Prospective or retrospective? • At the end of the call, negotiate when you will provide an answer.

6. Query #1 • Retrospective: • Which steroid did she take? • What dose? Route? Indication? • At what stage of pregnancy was steroid taken? • try & get exact dates if possible • Taking anything else? • Purpose of call? • for reassurance or because something abnormal has been detected on a scan?

7. Query #1 • Prospective: • Stage of pregnancy (weeks) • What is being treated? • Severity of condition? • Which steroid? Dose? Frequency? Route? • What has been tried already? • Is pregnancy currently ‘healthy & normal’? • Any co-morbidities? • Any other drug therapy being taken?

8. Query #2 • A junior doctor calls you and asks: “Is fluoxetine safe to use in a breastfeeding mother who is depressed?” • What additional information may be required in order for you to answer the query (or for you to refer the query to MI for answering)?

9. Query #2 • Who is calling? • Name, designation, contact details etc. • Patient specific or general? • Prospective or retrospective? • At the end of the call, negotiate when you will provide an answer.

10. Query #2 • Prospective • Was baby born at term? Is baby healthy and of normal weight for its age? • Has mum been treated for depression before e.g. while pregnant? If so, with what and did it work? • Proposed dose of fluoxetine to be used? • Co-morbidities for mum? • Other drug therapy for either mum or baby? • Is the GP open to suggestions of possible safer alternatives (if found)?

11. Query #2 • Retrospective: • Establish why GP is ringing? • e.g. for reassurance? Or is the baby showing signs or symptoms thought to be due to fluoxetine? • If so, further details as appropriate... • Was baby born at term & is baby healthy & of normal weight for its age? • Dose of fluoxetine used? • Co-morbidities for mum? • Other drug therapy for either mum or baby?

12. Query #3 • A registrar calls you and asks: “Is their an interaction between clarithromycin and citalopram?”

13. Query #3 • Who is calling? • Name, designation, contact details etc. • Patient specific or general? • Prospective or retrospective? • At the end of the call, negotiate when you will provide an answer.

14. Query #3 • Prospective: • Is citalopram a ‘long-term’ therapy and clarithromycin being prescribed ‘new’? • Proposed doses, duration etc. • Why clarithromycin? What infection is being treated? • Other drug therapy being taken?

15. Query #3 • Retrospective: • Establish why is GP ringing? • e.g. following a query to the GP from a community pharmacist, or because a patient is exhibiting a new symptom etc.?

16. Common Resources

17. Common resources used • BNF/BNFc • eMC • Martindale • DrugDex • AltMedDex • Stockley’s Drug Interactions • Natural Medicines Comprehensive database • CKS • TOXBASE • UpToDate • Patient.co.uk • NHS Choices • NHS Evidence • NEWT • Dosette box stability • Medline/EMBASE • Internet search engines • Pharmaceutical industry • Maudsley Prescribing Guidelines • Drugs in lactation database • Alerting/current awareness emails e.g. NICE, MHRA etc.

18. Question 1 • You need to find some information to advise a GP regarding nifedipine-induced gingival hyperplasia. • Where will you look?

19. Adverse Drug Reactions • Is it a recognised adverse effect? • Frequency it normally occurs? • Does the patient have any risk factors for experiencing the ADR? • Is the ADR transient/reversible? • Should the drug be stopped? • Is it a class effect? • What are the alternatives?

20. Reporting ADRs • Report: • all ADRs for new drugs (marked ▼) – even if mild • serious ADRs for established drugs when serious – even if well recognised • Serious ADRs include: • Vaccines / Unlicensed / Herbal medicines Causality does not need to be established

21. Should you report ......? Which of these reactions should be reported to the MHRA and why? • A patient who experiences nausea after taking amoxicillin • Liver damage as a result of taking a drug that has been on the market for 10 years • A patient who develops psoriasis which could be due to a herbal supplement they started 3 weeks ago • A bleeding peptic ulcer following treatment with diclofenac • An epileptic patient who fits after missing a dose of phenytoin

22. Completing a Yellow Card • Online www.yellowcard.mhra.gov.uk • simple and fast • drop-down menus • can register to save time in the future • can be saved part way through • App for use via tablets or smartphones • Paper • available in BNF, MIMs, ABPI • available from YCC Wales • download from MHRA website www.yellowcardwales.org

23. What happens to Yellow Card Data? • Drug analysis prints https://www.gov.uk/drug-analysis-prints • Drug Safety Updates • Nicorandil (Ikorel):now second-line treatment for angina; risk of ulcer complications • Levonorgestrel-releasing intrauterine systems:prescribe by brand name • MHRA can change licensing of a drug or withdraw license

24. Question 2 • You need to find some information for a GP so that he may advise a patient regarding the potential for interaction between ginkgo biloba and aspirin. • Where will you look?

25. Complementary and Alternative Medicine • A 2001 survey found 20% of adults in England had bought OTC herbal remedies in the previous 12 months • Pharmacists • should be able to advise the consumer on the rationale and safe use of all medicines • should have an understanding of the potential interactions and adverse effects alternative medication may have with conventional medicines

26. Complementary and Alternative Medicineacupuncture , homeopathy, herbal medicine, and manipulative therapies • Acupuncture • inserting fine needles into specific parts or points on the body along pathways called "meridians." • No known interaction with medication • risk of infection and increased bruising with anticoagulants • Homeopathy • Diluted products - little or no active ingredient. Unlikely that these preparations have any pharmacological effect, or adverse effect • No known interactions with medication

27. Complementary and Alternative Medicineacupuncture , homeopathy,herbal medicine, and manipulative therapies • St John’s Wort (SJW) (Hypericum perforatum) • Active ingredients and mechanisms of actions unclear • Cochrane concludes that SJW is more effective than placebo in the treatment of mild to moderate depression, and is more effective and better tolerated than standard antidepressants • SJW is a potent inducer or hepatic CYP enzymes. • SJW significantly decreases plasma concentrations of digoxin, HIV medication, oral contraceptive pills, theophylline, clozapine, warfarin and many more. Also theoretical risks with anticonvulsant medication...

28. Complementary and Alternative Medicineacupuncture , homeopathy, herbal medicine, and manipulative therapies • Chiropractic is “a health profession concerned with the diagnosis, treatment and prevention of mechanical disorders of the musculoskeletal system, and the effects of these disorders on the function of the nervous system and general health” • Caution with warfarin and anticoagulants • at least two reports of spinal epidural hematoma in patients taking warfarin who have received chiropractic cervical spine manipulation

29. Question 3 • You need to find some general information regarding the suggested management of Bell’s palsy. • Where will you look? Link

30. Question 4 • You are reviewing a guideline regarding people who misuse drugs etc. and need to determine the difference between a body-packer and a body-stuffer. • Where will you look? Link

31. Question 5 • A GP has received a query from a patient concerned that her “stomach pill” is going to give her dementia. You need to advise him so that he can reassure the patient. • Where will you look? Link

32. Question 6 • You wish to advise a GP which is the safest antidepressant to use empirically in a patient with cardiovascular disease? • Where will you look? Link

34. Question 7 • You need to advise a community pharmacist regarding the stability of Asasantin Retard in a compliance box. • Where will you look? Link

35. Question 8 • You need to advise a care home regarding administration of clopidogrel to a patient with swallowing difficulties. • Where will you look?

36. Common resources used • BNF/BNFc • eMC • Martindale • DrugDex • AltMedDex • Stockley’s Drug Interactions • Natural Medicines Comprehensive database • CKS • TOXBASE • UpToDate • Patient.co.uk • NHS Choices • NHS Evidence • NEWT • Dosette box stability • Medline/EMBASE • Internet search engines • Pharmaceutical industry • Maudsley Prescribing Guidelines • Drugs in lactation database • Alerting/current awareness emails e.g. NICE, MHRA etc.

37. Beware of the internet! • Some websites may contain information which is poorly evaluated, inaccurate and/or biased • Always consider: • Who are the authors? • Are key statements referenced? • Are the references reputable? • Is the information current? • Who owns or sponsors the site? • Is the site referred to by another authoritative site? • Always try and check an answer in another resource

38. The internet may be good for... • Branded or foreign products • Identification of drugs and herbal products • Hospital guidelines or formulary evaluations • News regarding ‘unusual’ treatments • Street drugs and substance misuse

39. The internet is not good for... • Drug interactions • ADRs • Formulation and compatibility queries • Pharmacoeconomics

40. Tablet identification We all love role-play! Volunteers please?

41. Communication skills

42. Communication skills • The tablet identification role-play shows the importance of clear, concise, accurate communication • When handling an MI enquiry, do not make any assumptions and, if in any doubt, ask for further clarification on any aspect of the query • When dealing with an MI enquiry, it is important to control the conversation in order to extract all relevant background information to view the query in context

43. Communication skills • Use a conversational tone (not a checklist!) • If necessary, consider explaining why you require the additional details you are requesting • Before ending the call, summarise the query to the enquirer (to ensure you & they agree what is being asked) • Agree a timescale for the answer (not “ASAP”)

44. Communication skills • Consider the format in which the answer is to be given • Verbal (face to face or telephone) • Written (email v.s. letter) • If giving an answer by telephone, the quality of your enquiry answering service is likely to be judged on the 2-3 minutes when giving the answer • Spending a few minutes summarising the main points of your answer e.g. using bullet points, ensures all relevant information is provided and helps to keep the conversation ‘on track’ • Recapping (you to the enquirer, or vice versa) may be helpful to ensure the message is delivered accurately

45. Communication skills • Verbal v.s. written answer? • Complexity of advice given? • How is the information going to be used? • Sometimes a verbal answer will require written confirmation • Email v.s. letter? • Style (formal v.s. less formal v.s. informal?) • Consider how the information is going to be used! • References? • Be aware of patient confidentiality issues • Patient identifiers & email addresses

46. Communication skills • When writing (or speaking), consider using phrases such as: • “As you will know,...” • “As you will be aware,...” • Avoid using phrases such as: • “There are no reports of ...” • Instead, use phrases like: • “Following a detailed literature search, I have been unable to locate any reports of...”

47. Over to you!

48. Ethical dilemmas

49. Ethical dilemmas – general points • You do not have to answer every question that you are asked. • Always give yourself thinking time before replying. • Consult with appropriate colleagues and/or managers before answering. • There is no one “right” answer to most ethical dilemmas, but you should be able to justify what you do.

50. Ethical dilemmas – general points • Do not answer queries that are beyond your sphere of expertise or available resources. • Research your answers thoroughly, and document carefully everything that you do. • Patients - Risk, product licences and healthcare politics, consequences, the Public Domain, fairness, appropriate, patient confidentiality