The Role of the Pharmacy in Adherence Support

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The Role of the Pharmacy in Adherence Support

  1. 1. The Expanding Role of Pharmacists<br />Supporting Sustainable Adherence to HIV Prevention, Care & Treatment<br />ICAP Technical Workshop<br />October 19-22, 2009Kigali, Rwanda<br />Angela G Giovanniello, Pharm.D.<br />Aby Leonard, Cote d’Ivoire<br />GideonChelule, Kenya<br />KidwellMatshotyana, South Africa<br />
  2. 2. Background<br />Suboptimal treatment exposure result in the failure of available regimens<br />Adherence is key to achieving successful treatment <br />Requires everyone to play a part <br />Regimens are complex and have little pharmacologic “forgiveness”<br />
  3. 3. Pharmacist Role<br />The care of the HIV-infected individual presents special challenges that warrant the need for a pharmacists intervention<br />Large number of drug interactions <br />Prescribed/ Herbal / Food<br />The need for poly-pharmacy for effective treatment <br />Medication pick-up ultimately last stop in the clinic<br />Provide time to recap or address any unmet issues<br />Disclosure issues <br />Barriers to family support or help<br />Incorporate family health to strengthen the family unit<br />Part of the multidisciplinary team<br />Referring when needed to counselors, clinicians, and lab personnel<br />
  4. 4. Potential Role of an HIV Pharmacist<br />Traditional Role<br />Dispensing<br />Inventory<br />Stock Management<br />Predictions<br />Tracking <br />Adherence<br />HIV Pharmacist<br />Approp. Drug Selection<br />Potency <br />Lack of interaction<br />Compatible with patient<br />Pre-therapy Counseling<br />Show & Tell<br />Drug/food restrictions<br />Side Effects<br />Adherence<br />Follow-up<br />Adherence<br />Tolerance/Toxicity<br />
  5. 5. Opportunity for Intervention<br />Frequent patient interactions (monthly medication pick-up )<br />Allowing for engagement <br />Side effect/ toxicity identification <br />Quickly detect any adherence problems<br />Verify appropriate dosing and administration schedules<br />
  6. 6. Case 1<br />AK is a 39 yo female <br />Started on HAART 2 months ago coming for her first medication refill <br />She has missed her medical follow-up appointment <br />Prompt a discussion about the timing of her medication pick-up<br />AK reveals she has a lot of diarrhea on the days she takes her medication and can not take her medications on the days she has to be out of the house.<br />
  7. 7. Adherence Measures<br />3 day recall<br />In the past 3 days how many doses have you missed?<br />7 day recall<br />When was the last dose you missed?<br />What would make your regimen easier?<br />Pill count<br />Refill dates <br />
  8. 8. Adherence Tools<br />
  9. 9. Adherence Tools<br />Pillboxes<br />Alarms<br />Cellphones<br />Blister packaging<br />Peers – social supports<br />MEMS caps<br />
  10. 10. Barriers to Adherence<br />Lack of education <br />Adherence goals <br />most pt do not know that &gt; 95% is the goal <br />If missing more then 1 day per month under 95%<br />Resistance <br />Evaluate barriers to adherence<br />Create a rapport – include family when possible<br />Depression <br />Side Effects/ Drug toxicity <br />Active substance abuse <br />Literacy<br />
  11. 11. Case 2<br />EH is a 16 yo pregnant female coming to the clinic for prenatal care <br />Started on HAART consisting of NVP/3TC/d4T <br />Experiencing continued vomiting over the past 2 days due to the pregnancy and has been unable to continue the prescribed treatment<br />Based on the pharmacokinetic properties of her medications can she just stop all her medications? <br />
  12. 12. NNRTI PK Problems<br />Prolonged half-life with a greater risk of developing regimen crippling mutations <br />Possible utility of continuing NRTI’s of the regimen to prevent this occurrence <br />Recommendations vary from 7 to 14 days of continued NRTI treatment after the discontinuation of the NNRTI<br />Others have recommended swapping NNRTI’s to LPV/r for 1 month then discontinuation of all agents<br />
  13. 13. Case 3<br />MM a patient doing well on a regimen <br />AZT/3TC/NVP * 6 months <br />Diagnosed with TB and placed on<br />Isoniazid/Rifampin/Pyrazinamide/Ethambutol <br />Comes to the pharmacy for the additional treatment <br />What discussion occurs?<br />
  14. 14. Key Drug-Drug Interactions<br />Rifampicin – potent CYP isoenzyme inducer<br />Alters drug concentrations of most ARV’s significantly<br />Changes to alternate ARV’s possible option<br />NVP  EFV <br />
  15. 15. Case 4<br />ZR a 1 yo male comes for a monthly medication <br />d4T/3TC/NVP<br />The baby is healthy and developing well<br />Tolerating all medications<br />No present issues with adherence to liquids<br />Doses have remained the same for the past 3 months <br />Is this alarming?<br />
  16. 16. Patient<br />Provider<br />Change in Dynamic<br />Patient<br />Provider<br />RPH<br />
  17. 17. Key Points <br />Small steps incorporate 2 steps to each prescription.<br />Check refill dates <br />Check log and see if dates make sense<br />Ask simple questions about tolerability of ARV’s<br />Have you been having any problems that have made taking your medications difficult?<br />Any nausea/vomiting?<br />Any rash developments?<br />CNS SE of efavirenz? <br />
  18. 18.
  19. 19. ICAP Country Examples: Pharmacy Support for Adherence<br /><ul><li>Cote d’Ivoire – Role of Pharmacy in Patient Education
  20. 20. Kenya – Integrated Appointment and Adherence Assessment
  21. 21. South Africa – Development of VAS and Task Shifting</li></li></ul><li>Cote d’Ivoire Traditional Overview Role of Pharmacy<br />Ensure the availability of drugs and laboratory reagents (firstly)<br />Ensure drugs management and dispensing.<br />Ensure adherence to treatment through advices and treatment explanation<br />Ensure the pharmacological monitoring of the treatments introduced (Ensure the prescription conformity)<br />Implement pharmacy database<br />Pharmacovigilance<br />
  22. 22. Cote d’IvoirePharmacy and Peer Educator Collaboration<br />Peer Educatoris the continuation of the pharmacist in the community<br />Pharmacistreinforce and deepen the Peer Educatorknowledge on ART treatment.<br /><ul><li>Pharmacist and PE share information on patients (diary, dispensingregister, etc.)</li></ul>Pharmacistencourages patients to see the PE aftereach ART dispensingto reinforceadherence<br />Strengthen communication betweenPharmacist, data officer and PE <br /><ul><li>Share information to allowverification of appointments, lost to follow up, deathsand other information</li></li></ul><li>Cote d’IvoirePharmacy and Support Group Linkages <br />Pharmacistinforms and remindspatients of the available support group<br />Pharmacistshouldleadsome sessions on adherenceat the support group on site <br />Discussion of the benefit of adherence to treatment, pharmacovigilance, and provideadvicewhichcan help withadherence.<br />
  23. 23. Kenya<br /><ul><li>Pill count done at pharmacy
  24. 24. An integrated diary able to book appointment and record pill count was developed.
  25. 25. A formulae was integrated into the diary
  26. 26. Integrated Diary was then stationed at the pharmacy</li></ul>Developing Integrated Appointment and Adherence Assessment System<br />
  27. 27. Kenya<br /><ul><li>Task shifting to peer educators stationed at pharmacy was done
  28. 28. Adherence assessment (including pill count) integrated in APS training curriculum
  29. 29. Patients asked to return pill balances at every visit
  30. 30. Patients collect their repeat medication on scheduled dates of appointment (28 day cycle pick-up)
  31. 31. Adherence is then assessed</li></ul>Implementing Integrated Appointment and Adherence Assessment System<br />
  32. 32. Diary<br />
  33. 33. South Africa<br /><ul><li>Overview Role of Pharmacy in South Africa Care and Treatment
  34. 34. Aim of pharmacy support is to provide a comprehensive pharmaceutical service at all ICAP supported sites
  35. 35. Quality of care is at the centre
  36. 36. Monitoring treatment outcomes through pharmacovigilance and adherence monitoring systems
  37. 37. Monitor & support drug availability – all essential drugs in the program (anti-TB/ARV/OI)
  38. 38. Compliance with minimum standards of pharmacy practice – legal requirement </li></li></ul><li>South Africa<br /><ul><li>Development and Use of VAS…
  39. 39. Various methods used in assessing adherence : pill counts, appointment schedule, patient interviews / checklists,
  40. 40. Pill boxes, alarm clocks, treatment diaries, treatment buddy
  41. 41. There is no one effective system in monitoring and assessing adherence
  42. 42. Adult Patient Adherence Record and Monitoring Form
  43. 43. Owned by the National DOH
  44. 44. Consists of: Pill Identification test, medication pick-up dates, Pill counts, Visual Analogue Scale, patient self reporting
  45. 45. A comprehensive system to improve adherence
  46. 46. Time consuming on the user but very effective in developing a stepped-up adherence plan</li></li></ul><li>South Africa<br /><ul><li>Opportunities for Task Shifting to PEs….
  47. 47. PE tend to understand local languages
  48. 48. They interact with the patients in the community and in the local HIV support group (PLHIV support group)
  49. 49. Clinicians do not have enough time
  50. 50. The large number of patients at each sites
  51. 51. Some clinics have 3 PE and 1 PN, no pharmacy personnel,
  52. 52. PE can do pill counts, VAS, Pill identification
  53. 53. Clinicians – Patient self-reporting & interviewing then developing a plan to improve adherence. </li>

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