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Prescribing Basics: Common Medications, PSA Overview, Controlled Drugs, Anticoagulation

This resource covers the basics of prescribing common medications, provides an overview of the prescribing safety assessment (PSA), discusses controlled drugs, and offers guidance on anticoagulation. It includes information on drug names, doses, routes, quantities, and timings, as well as considerations for antibiotics and PRN medications. The resource also covers the use of controlled drugs, including prescribing protocols and required documentation. Additionally, it provides guidance on anticoagulation management and includes case examples.

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Prescribing Basics: Common Medications, PSA Overview, Controlled Drugs, Anticoagulation

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  1. Prescribing Teaching 3 C. Maduanusi c.maduanusi@nhs.net Max Roberts max.roberts@nhs.net

  2. The basics Aims & Objectives • Practice prescribing common medications • PSA overview • Controlled Drugs • Anticoagulation

  3. The Common Things Common things

  4. The basics The basics • All drugs • Drug name, dose, route, quantity, time, signature & name, bleep no. • Antibiotics – add duration, indication and review/stop date • PRN – add maximum frequency, indications Paracetamol 1g PO Dr Pain xx/xx Co-amoxiclav 1.2g IV xx/xx xx+2/xx10 days Dr Pen 123 Pyelonephritis 14

  5. Funny times… Funny Times

  6. Consider the systems Cytochrome P450

  7. PSA Format

  8. PSA 1 – Prescribing (10) https://www.google.com/search?q=pulmonary+oedema+cxr&rlz=1C1GCEA_enGB869GB869&source=lnms&tbm=isch&sa=X&ved=0ahUKEwiJ7tLsoYDlAhWToFwKHXJ6DRIQ_AUIEigB&biw=1600&bih=740#imgrc=m7xJYJ-odU85OM: Mr Jones presented to A&E with acute shortness of breath. He described days of decreased exercise tolerance and a persistent cough with white frothy sputum. PMH: HTN. NKDA. DH: Amlodipine 10mg OD Or Examination Airway patent. Chest – bibasal coarse crackles, RR 22, S: 91%. HS I+II+O. JVP +5cm. HR 101, BP 105/75. Abdomen soft and non tender. Pitting oedema to the mid-thighs. Sacral oedema. BM 6. GCS 15 Investigations: WCC 5 Hb 134 Plat 340 Na 140, K 4.3 Urea 5 Creat 70 CRP 3 BNP 500 CXR illustrated Please prescribe an appropriate once only medication that could be used to alleviate his symptoms. Xx/xx Furosemide 40mg IV Doctor Doctor

  9. Controlled drugs • What are controlled drugs? • Medicines which are ‘controlled’ under the Misuse of Drugs Act • These include opioids, benzodiazepines, ketamine, THC, Z-drugs, barbiturates, etc • They need to be locked up on the wards • Patients may need proof of identity for their prescriptions • Doctors need to specify exact quantities

  10. Controlled drugs • Drug name and formulation • Words and figures • Strength • Dose • Quantity • Frequency, route • Sign, date, bleep Please supply 2 (two) patches of buprenorphine 5 (five) microgram/hour, 1 (one) patch once weekly on Fridays, weekly

  11. Controlled drugs • Prescribe a two-week TTO for: • morphine MR 10mg BD PO • morphine sulphate concentrated solution (10mg/5mL), 2mg, max frequency 4 hourly PRN PO • buprenorphine 5microgram/hour patch. Top. OW on Mon • Please supply: • 28 (twenty-eight) tablets of morphine sulphate MR 10 (ten) mg, 1 (one) tablet twice a day, by mouth • 100 (one hundred) mL of morphine sulphate concentrated solution 10mg/5mL (ten mg / five mL), 1 (one) ml when required, maximum frequency 4 hourly, by mouth • 2 (two) patches of buprenorphine 5 (five) micrograms/hour, 1 (one) patch once weekly on Mondays, topical

  12. Controlled drugs Please prescribe an appropriate PRN medication for breakthrough pain. Oramorph 10mg PO 4 hrly Doctor 123 Doctor . xx/xx Morphine MST MR 30mg PO Doctor xx/xx For breakthrough pain, give ~1/6th of the total regular daily dose, every 4hrs

  13. Controlled drugs Please adjust the analgesic medication for this patient. Yesterday Yesterday Yesterday Yesterday 5mg 5mg 10mg 10mg 10mg 10mg 10mg Morphine MST MR 20mg PO Doctor xx/xx Oramorph 5-10mg PO 2-4 hrly Doctor 123 Doctor . xx/xx Increase morphine doses by 25-50% per day

  14. Controlled drugs Please adjust the analgesic medication for this patient. Morphine MST MR 30mg PO Doctor xx/xx Oramorph 10mg PO 4 hrly Doctor 123 Doctor . xx/xx Increase morphine doses by 25-50% per day

  15. Morphine MST MR 30mg PO Doctor xx/xx Codeine 30mg PO Doctor xx/xx https://www.publichealth.com.ng/clinical-opioid-conversion-charts-tips-guides-and-templates-pdf/ Please start this patient on a syringe driver. They are comfortable on their current regime.

  16. Codeine is 3-methoxymorphine In the body, it gets demethylated to become morphine A dose of codeine is equivalent to 1/10th the dose of morphine i.e 100mg codeine = 10mg morphine 1) Total morphine MR dose = 30mg TDS = 90mg over 24hrs 2) Total codeine dose = 30mg QDS = 120mg over 24hrs = 12mg morphine over 24hrs So overall morphine dose = 102mg oral dose over 24hrs

  17. Morphine 50mg Over 24hrs SC Doctor 123 xx/xx Via syringe driver Oxycodone 35mg Over 24hrs SC Doctor 123 xx/xx Via syringe driver

  18. Hydromorphine 10mg Over 24hrs SC Doctor 123 xx/xx Via syringe driver Alfentanil 3.5mg Over 24hrs SC Doctor 123 xx/xx Via syringe driver

  19. https://www.northkirkleesccg.nhs.uk/wp-content/uploads/2013/07/Guidance-on-Prescribing-Anticipatory-Drugs-and-Syringe-Drivers-in-the-Community.pdfhttps://www.northkirkleesccg.nhs.uk/wp-content/uploads/2013/07/Guidance-on-Prescribing-Anticipatory-Drugs-and-Syringe-Drivers-in-the-Community.pdf

  20. Anticoagulation Mrs Brown (DOB 13/11/1940) presented to her GP with mild lightheadedness. The following ECG was taken. A 24-hour Holter monitor confirmed the findings. PMH: T2DM, diet-controlled DH: nil Or Examination BP 120/80, HR 70, weight 70kg, nil else of note Investigations: WCC 5 Hb 134 Plat 340 INR 1.0 Na 140 K 4.3 Urea 5 Cr 70 eGFR >90 LFTs NAD https://ekg.academy/learn-ekg?courseid=312&seq=13 Please start this patient on an appropriate medication for stroke prevention (use the inpatient chart).

  21. CHA2DS2-VASc CHF 1 point Hypertension 1 (>140/90 or on Tx) Age over 75yr 2 Diabetes 1 Stroke/TIA 2 Vascular disease 1 (e.g MI, PVD) Age 65-74yr 1 Sex category 1 if female HAS-BLED 1 for each Hypertension >160 sys Abnormal liver/kidney function Stroke Bleeding Labile INRs Elderly: 65yr or older Drugs (anti-platelets, alcohol >8 units/week) CHA2DS2-VASc = 4, HAS-BLED = 1

  22. Warfarin 2 – 3 AF Today 1.0 5mg Doctor Doctor Tomorrow 1.0 5mg Doctor Doctor Day after check INR What might you prescribe alongside warfarin? Rivaroxaban 20mg PO Doctor Doctor123 xx/xx Take with food

  23. Dabigatran 150mg PO Doctor Doctor123 xx/xx Apixaban 5mg PO Doctor Doctor123 xx/xx What else do we need to do once we’ve decided to start anticoagulation?

  24. https://www.pharmaceutical-journal.com/news-and-analysis/community-pharmacy-plays-its-part-in-making-anticoagulation-therapy-safer/10005896.article?firstPass=falsehttps://www.pharmaceutical-journal.com/news-and-analysis/community-pharmacy-plays-its-part-in-making-anticoagulation-therapy-safer/10005896.article?firstPass=false http://www.ashfordstpeters.nhs.uk/press-releases-in-2016/203-anticoagulation-clinic/601-anticoagulation-clinic

  25. Anticoagulation Adjust this patient’s warfarin regime Warfarin 2 – 3 AF Yesterday 5mg Doctor Doctor Today 1.8 6mg Doctor Doctor Tomorrow 6mg Doctor Doctor check INR In general, when adjusting the dose, a 15% change in dose is expected to result in a change in the INR of 1 What else do we want to review?

  26. Anticoagulation Prescribe appropriate treatment in the following clinical scenarios for a 70kg patient: • INR 6.5, no bleeding • INR 8.5, mild epistaxis • INR 3.5, haematemesis

  27. Anticoagulation For all three cases: Warfarin 2 – 3 AF Today Doctor Doctor Tomorrow Doctor Doctor What else would you want to review?

  28. Anticoagulation a) INR 6.5, no bleeding Warfarin 2 – 3 AF Today 6.5 Doctor Doctor Tomorrow Doctor Doctor check INR Restart when INR <5.0, at a lower dose

  29. Anticoagulation b) INR 8.5, mild epistaxis Today STAT Vitamin K / phytomenadione 1mg IV Doctor Repeat vit K dose if INR still raised after 24hrs Restart when INR <5.0, at a lower dose

  30. Anticoagulation c) INR 3.5, haematemesis Today STAT Vitamin K / phytomenadione5mg IV Doctor Today STAT Beriplex / dried prothrombin 1750 units IV Doctor complex concentrate (25 units/kg) What could you prescribe as an alternative to prothrombin complex concentrate?

  31. Pt on warfarin No bleeding Minor bleeding Major bleeding IV vitamin K, 5mg Prothrombin complex concentrate (FFP) IV vitamin K, 1-3mg INR >8.0 INR 5.0-8.0 nil else PO vitamin K, 1-5mg • Withhold/stop warfarin for all patients • Check for interactions

  32. Thanks! Any questions? www.surveymonkey.co.uk/r/29Z3VF5

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