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Medicines Information for the Primary Care Pharmacist Noshi Iqbal Lead PharmacistClinical Training & Development November 2007
Learning Outcomes� By the end of this session, you will be able to:� Use the most appropriate reference source to answer common MI enquiries� Know when to refer enquiries to Medicines Information Centres
Problems faced by Primary CarePharmacists� Don’t have access to general resources that would be available in a Pharmacy or Med Info Centre.� Limited to the Internet, most websites need registering or subscriptions.� Doubt over reliable and trustworthy sites for information.
Types of MI Enquiries in PrimaryCare� General medical & pharmacy enquiries (dosage, frequency, formulation)� Immunisation & travel advice� Adverse drug reactions & drug interactions� Drugs in Pregnancy & Lactation� Renal & hepatic disease� Paediatrics (off-licence use of drugs)� Specialist queries (mental health, cancer)� Miscellaneous (out of stock)
Joining the Bradford & AiredaleMedical Libraries� Joining any of the four libraries below automatically provides access to all four facilities, including borrowing rights and other services. Show your ID badge to join.� Bradford & Airedale tPCT Library Service Library Team, Ground Floor, Douglas Mill, Bowling Old Lane, Bradford, BD5 3JR Tel: 01274 237484 Fax: 01274 539232� E-Mail - firstname.lastname@example.org� Airedale NHS Trust Library and Information Service Medical Education Centre, Airedale General Hospital, Skipton Road, Keighley, BD20 6TD. Tel: 01535 294412 Fax: 01535 292196 E-mail - email@example.com� Library & Health Promotion Resources Lynfield Mount Hospital, Heights Lane, Bradford, BD9 6DP� Tel: 01274 363194 Fax: 01274 363194 E-Mail - firstname.lastname@example.org� Bradford Teaching Hospitals Health Library & Information Service� Field House, BRI.� NHS staff in Bradford & Airedale are also permitted to join and borrow from: Universities of Leeds & Bradford
Obtaining an athens log-in� Access hundreds of journals online� Wealth of information� Most key journals offer full text (though available after 6 months)� Library services will allow photocopy of current journals (within copyright guidelines)� Need to contact Rebecca Hewitt (let her know that you work for Bradford & Airedale tPCT): email@example.com or 01274 237484� Webpage: http://www.athensams.net/ and click on ‘MyAthens’ on left hand side.� Once you have joined the library service it will be easier to obtain an athens password. The libraries have many publications on athens access and registration.
British National Formulary� Most important reference source� Available online at www.bnf.org� Need to log-in with athens or personal log-in (need to register for)� Advantage of online BNF that can copy & paste info from webpage straight into patient’s records� Can link straight through to a drug monograph from SystmOne (right click on drug, scroll down to BNF information). Will need to log-in at BNF screen (some practices can do straight link without log-in).� Children’s BNF available online at http://bnfc.org/bnfc/
Online Medicines Compendium � Full Summary of Product Characteristics (SPC’s) and Patient Information Leaflets (PILs) available for the majority of drugs � No log-in needed � Information can be copied and pasted in patient records � PILs can be downloaded and saved in pdf � SPC’s and PILs can be printed � Contact telephone numbers for drug manufacturer’s med info dept or customer services provided
MIMS� Available online at www.healthcarerepublic. com//home/pharmacist� Registration required� Unfortunately, cannot access clinical tables / guides without subscription� However, can obtain info Can sign up to receive free weekly email bulletins which have on latest products and a summary of the best pharmacist licence changes clinical features, jobs and news
PACE Guidelines� Available online at http://www.learnonline.nhs.uk/P ACE� PACE are responsible for bringing together national guidance and local specialist expertise in Bradford and Airedale around the promotion of good health and the prevention and treatment of ill health. This consists of a guidance document, educational learning events, evidence-based tool kits and district wide clinical audit. PACE Team� Guidelines and toolkits are 2nd Floor available on site to be viewed Douglas Mill and downloaded. Bowling Old Lane� Pharmacists are encouraged to Bradford attend PACE educational events BD5 7JR (as long as practices are not Tel: 01274 237406 disrupted significantly and work is covered) Email: firstname.lastname@example.org
ADRs & Yellow Card data� As pharmacists we have duty to fill in yellow cards if we come across an ADR with any drug during med reviews with patients.� Keep a copy for yourselves and send CMS a copy (looks good on record).� Sometimes need to know if a particular drug is cause for an ADR – can look at yellow card data though bear in mind that this info is not a true reflection of incidence, but is info on reports submitted� Yellow card data is (for the majority of �Availableon the MHRA website cases) better than ringing the company med info dept as they then �www.mhra.gov.uk have a legal right to know about �Monographs are called: patient details, and there is a risk of ‘Drug Analysis Prints (DAPs)’ breaching patient confidentiality and obtaining consent could alarm patient etc. Example of monograph (fluoxetine)� Yellow card data provides an Key tip – MHRA website is awful to alternative source of info when the use. To find DAPs go to main site, BNF & SPC does not mention the and change last digit of web ADR. address ‘5’ to ‘742’. Will take you direct to the DAPs page.
Product Availability� Common enquiries via patients that cannot get hold of their medicines, or referred from GP asking about supply problem and whether worth switching patient to alternative� UCLH Solutions website detailed list of product problems� www.uclhsolutions.com� Username & password: cmspharmacists� Click on – solutions – product shortage list for list of drugs Can print off whole list as pdf document with supply problems and date (updated weekly) to give to for resolution community pharmacists / GPs� Can confirm discontinuations� MHRA drug recalls all available
UKMi national website� UK Medicines Information Network homepage� www.ukmi.nhs.uk� Most clinical areas are password protected for MI pharmacists� Useful to know as a pharmacist which clinical areas available to help with enquiry (can then ring MI to ask answer)� Website has a fridge database and a latex database – big lists of products� Most other clinical sections are directed to other websites (mostly NeLM)
National electronic Library forMedicines (NeLM)� www.nelm.nhs.uk� Need to register� Previously known as ‘druginfozone’� Registration enables daily MI email alerts� One of the best MI sites available� Previously NPA resources (travel immunisation, malaria prophylaxis, diluents, sugar Q and A section has reviewed and contents, E-numbers) all critically evaluated answers to available to download, now common questions. Have all been removed updated (currently 129 Qs available).� Info on drugs on the horizon Examples:� Large section for prescribing 1) Is it safe to use metformin in HF? (for pharmacists) 2) Switching between antidepressants
Primary Care Question AnsweringService� www.clinicalanswers. nhs.uk� Similar to NeLM Q&A but more specific to primary care� All questions are answered with references but are limited in depth (are not systematic reviews)� Can view questions References are common primary care by speciality sources like prodigy and CKS, (condition) or can but summarised concisely search site
Clinical Knowledge Summaries(CKS)� Incorporates Prodigy� Part of NHS Libraries� Useful info on disease management� Covers drug treatments� Easy to use site� Can print leaflets for patients� Need to register
National Prescribing Centre (NPC)� www.npc.co.uk� Being updated at moment� MeReC bulletins, therapeutic reference sheets, info on new medicines on horizon� Medicines Management & Partnership sections etc� Vast source of information
National Service Frameworks (NSFs)� Available on the DoH website� www.dh.gov.uk� NSFs are long term strategies for improving specific areas of care. They set measurable goals within set Can also download the ‘Green Book’ time frames. From DoH site (vaccination & immunisation Guide)� All available to download from site
National Institute of Clinical Excellence (NICE) � NICE is an independent organisation responsible forIn the “Our Guidance” section, the providing national guidance ondifferent types of guidance that NICE promoting good health and preventing and treating illproduces (e.g. Technology Appraisals, health.Clinical Guidelines and Interventional � Appraisals & guidelinesProcedures) can be found – both those available to download as fullfinalised and those in progress. documents or summariesThe Guidance can be found by: � www.nice.org.ukLooking at the list of ‘type’ i.e.Technology appraisals, ClinicalGuidelines or Interventionalprocedures.Looking at the list of ‘topics’, whichcategorise guidance into health topics.Looking in the Compilation, which is asummary of all the Guidanceproduced.
Immunisation & vaccination� www.immunisation. nhs.uk� Information on all the vaccines and immunisation schedules� Refers to other sources for links� Easy to use site – good to recommend to patients for further information
Enquiries to refer toMedicines Information Centres
Enquires that need to be referred toa MI Centre� Pregnancy & Breastfeeding� Complex renal & hepatic disease� Paediatric (especially neonate) where off-licence info is required� IV enquiries� Herbal interaction enquiries� Specialist enquiries – psychiatric drugs, chemotherapy
Ringing Medicines Information� Each hospital has a MI Centre; then there are regional (specialist centres e.g. Newcastle is specialist for pregnancy & poisoning).� Some hospitals (e.g. Bradford) are not funded to provide a MI service to primary care so they may try to brush you off (they have an overwhelming number of enquiries to deal with). However, they cannot refuse to take your call as this would be against UKMi protocol.� Try and ring MI only when the enquiry is complex, and needs specialist input. The more time you can give them to prepare the answer the better response you will get.� Bradford MI: 01274 364598
MI requirements � MI Centres tend to ask a lot of questions in order for them to prepare a comprehensive answer for you, so ensure you know all the details and have done the basic looking up.
Key questions to think about when doing MIMI Centres will ask you thesequestions so try to know theiranswers before ringing them
General questions – for all enquiries � Is this a general enquiry or is it about a specific patient? � What is your name? � What is your job/your role/your interest in this enquiry? � How should I contact you? � When do you need an answer?
Adverse drug reactions� Establish patient’s age if relevant� Ask about the indication for the drug and any relevant medical history (e.g. renal function)� List all current and recent drugs (include OTC products, herbal medicines, drug abuse).� Consider any history of ADRs and or allergies.� Ask for the details of the suspected reaction including signs & symptoms, and severity.� Establish when the suspected reaction began (especially in relation to starting drug treatment) and whether the drug has been stopped.� Ask how the patient has managed and how he/she is now.Remember to check yellow card data when dealing with ADRs
Drug interactions� Which of the drugs is the patient already taking? How long have they been taken for?� Has the enquirer or patient read about an interaction somewhere? If so, where?� If the patient is already taking both drugs, have any problems been identified or investigated?� If there is an interaction, is there any reason why alternative drugs can’t be used instead?� What is the patient’s liver and renal function?� Is the patient taking any other medicines?� If any ongoing or future monitoring would be required, who would do this?
Drugs in breast-feeding� Identify drug, indication, dose, frequency, route of administration and duration of treatment.� What would happen if the drug is stopped, or not used?� Has any alternative been considered or tried?� Has mum already been taking the drug? Has the baby already been exposed to it in pregnancy or breast- feeding, and if so have any problems been identified?� How old is the infant, and is he/she premature or full- term?� Is the baby well? Is there anything to suggest that the infant may be at increased risk of drug harm – such as impaired kidney or liver dysfunction?� Who is in a position to change therapy if necessary or document your advice in the patient’s notes? Who else needs to know the answer to this enquiry?
Drugs in renal disease� Establish age, weight and height of patient.� Check the degree of renal failure, whether it is acute or chronic, and whether renal function is stable, deteriorating or fluctuating.� Is the patient currently taking the drug in question, if so what dose and frequency?� What is the indication for the drug and have alternatives been considered?� Which if any, renal replacement therapy is being used?� Ask about the timing of any renal replacement therapy as necessary.
Drugs in liver disease� Establish the clinical condition of the patient, age, and presumed diagnosis.� Results of LFTs (including clotting screen), biopsies and other diagnostic liver tests. Are the LFTs stable or changing?� What is the patient’s renal function?� If drug-induced hepatotoxicity is suspected, is the patient currently taking the drug in question, if so what dose and frequency? What other drugs are being taken or were taken recently?� If requesting advice on dosage or suitability of a drug in hepatic dysfunction, what is the indication for the drug and have alternatives been considered? What agent would normally be used if the patient did not have liver dysfunction?
Pharmacokinetics� Identify the drug, indication, dose, frequency, route and duration of therapy.� Check the patient’s age, gender, weight, concurrent medication and medical history including renal and hepatic function.� Check if any previous drug levels have been taken and if so, check the exact time they were taken in relation to the drug and confirm the units of measurement.� Have any interacting drugs been started (or stopped) which may affect levels?
Palliative care� If enquirer asks about compatibility of drugs in a syringe driver, check the drugs, doses, diluent and volume. If you are unable to find compatibility data, think about alternative drugs, routes or separate syringe drivers.� If enquirer asks about symptom control, establish indication and what drug or non-drug options they have tried already.� If the patient is unable to tolerate oral administration, explore other routes with enquirer.� Check concomitant medication and concurrent disease including renal and liver function.
Alternative medicine� Is the patient already taking the alternative medicine or do they want to start taking it?� Identify the alternative medicine, indication, route, strength, dose and frequency. If applicable, how long has it been taken for?� Has the patient self-diagnosed the condition that they are seeking to treat? If they have, perhaps they should consider speaking to a healthcare professional first.� Does the patient take any conventional medication? Is there any history of ADRs or allergies?� Check the past medical history.
Substance misuse� How certain are you that the amount of drug taken and the frequency of use is correct? Users may lie about the quantities consumed and the purity of street drugs also varies very widely.� Has a urine screen been organised? What were the results?� Does use of the drug relate to a single exposure, short- term use, or a persistent habit?� How is the subject taking the drug (e.g. injection, oral)?� Is the subject taking other drugs? It may be important to know about other substances (e.g. tobacco, prescribed drugs): some enquirers panic when they hear about an illicit drug, or automatically blame it for all the patient’s problems, and don’t ask further questions.� If the enquirer has used drug slang terms that you are not familiar with, ask them to clarify.� Many enquiries concern side effects, interactions or use in pregnancy.
Travel Medicine� Identify the traveller(s).� Check age, concurrent medication and medical history (e.g. acute illness, immunosuppression, psoriasis, epilepsy, neuropsychiatric disorders, renal or hepatic impairment).� Check whether any female travellers are pregnant or breast-feeding.� Identify the exact destination(s) to be visited.� Find out about the nature of the travel and type of accomodation (i.e. is traveller backpacking through rural areas or staying in a good quality urban hotel?� Check the length of stay and the proposed travel date.
Immunisation� Identify the vaccine that is to be administered (is it live or not?)� If it’s not obvious, ask about why the vaccine is required, and when.� Is the vaccine really necessary? Even if it is necessary, could delaying vaccination help solve the enquirer’s problem? Does the patient require a primary course or a booster dose?� If relevant, enquire about which vaccines the patient has had before.� Does the patient have any contra-indication to vaccination? Consider acute illness, previous allergy or adverse reactions, pregnancy and immunosuppresion.� Ask about concurrent disease and concomitant medication.Use the ‘Green Book’ available on the DoH website.
Product availability� Why do you need this product? Why is an alternative in the BNF not acceptable?� What is the product to be used for?� Establish where the enquirer heard about the product.� Ask for exact spelling, any known manufacturer, strength, dosage form and country of origin.� Ask how much is needed, and when it is required.Remember to use UCLH website, can always ring customer services at drug companies for confirmation about availability.Unlicensed specialists like IDIS & Durbin may be able to source supply of drug.
Drugs in Pregnancy� Assess whether prospective or retrospective exposure – is the woman actually pregnant now, or planning to become pregnant?� Identify the drug, indication, dose, frequency, route, and the duration of exposure.� How many weeks pregnant was the woman when she first started taking the drug?� How many weeks pregnant is she now?� What drug has the woman taken during previous pregnancies for any similar condition?� Has the woman taken the drug in question during a previous pregnancy?� Has the woman had any previous pregnancies and what was the outcome?� Is there a family history of malformations or history of recurrent abortions?� Have any investigations been performed (e.g. ultrasound scans)?� For chemical exposure enquiries additional questioning may be needed to establish substance involved, approximate quantities, duration of exposure per day, protective measures taken etc.
Administration of medicines� If asked about administration of IV drugs think about: dose, infusion fluid, fluid volume, rate, availability of intravenous access and whether any other drugs are being given IV.� For drugs put down enteral feeding tubes, ask about: type of tube, where the end of the tube is, & the feeding regimen. Think about alternative administration routes or drugs.� If the enquiry is about a patient who is NBM prior to surgery establish the drugs & doses, and the duration of expected NBM. Again, think about alternative routes or drugs.� Similarly if a patient becomes dysphagic, ask about the drugs & doses and when/whether their swallow is expected to improve.Hospitals have a Wrexham Maelor Hospital & NEEMMC guidelines to deal with crushing tablets enquiries (can ring company too).
Compatibility of parenteral drugs� Which drugs are currently being mixed?� Which drugs are you planning to mix?� What are the concentrations of the drugs, and what diluents are being used?� How will the drugs be mixed and what types of IV lines are being used?� Which of the drugs to be mixed are essential? (if not obvious)� What other drugs is the patient being given parenterally?� Is the number of IV access points limited? If so, why?� Can alternative routes of administration be considered? If not, why?� Establish how the patient is fed – an enteral feed tube offers a potential alternative administration route; if TPN is being used this can create additional compatibility problems.
Clinical trials � If you are asked to identify a specific clinical trial, gather as much data as possible about the trial before trying to look for it: drug name, manufacturer, date of publication, disease area, any acronym, authors’ names and so on. � Check with the drug company / trial rep for further info. � Check NeLM website for info
Choice of therapy & drug dosing� Check the indication even if it appears obvious (e.g. don’t assume amitriptyline is for depression) and the preferred route.� Check the patient’s age and weight if appropriate.� Check the patient’s renal and liver function.� Check the past medical history to ensure the drug is appropriate for the patient.� Does the patient take any other medicines?� Has the patient tried any other drug/non-drug therapy already?� Does the patient have any allergies?
Stuck? � Give Noshi a ring � New mobile number – 07515 278437 � Bradford’s ex-MI Pharmacist (2.5 years)Medicines Information is fun – providing information is animportant part of being a pharmacist