Medicines Information

1. Medicines Information for future pharmacists Spring 2018

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 flu vaccines 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 vaccine did she take? • What dose? Route? Indication? • At what stage of pregnancy was vaccine 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: • Which flu vaccine to be given? • Any co-morbidities? • Any other drug therapy being taken? • History of past pregnancies e.g. Medication/vaccines used in previous pregnancies • Any known drug allergies • Any egg allergies? Or any previous problems with vaccines

8. Query #2 • A member of the public asks you: “Is codeine safe to use while breastfeeding?” • 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, contact details etc. • Patient/personally specific or general? • Prospective or retrospective? • Establish when they need an answer.

10. Query #2 • Prospective • Has mum been treated for pain before e.g. while pregnant? If so, with what and did it work? • Co-morbidities for mum? • Other drug therapy for either mum or baby? • Has this conversation been had with other healthcare professionals e.g. Midwife – it might have already been done on MiDatabank for this specific patient

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

12. Query #3 • A registrar calls you while your driving home on-call and asks: “Is there an interaction between ciprofloxacin and sodium valporate?”

13. Query #3 • Who is calling? • Name, designation, contact details etc. • Patient specific or general? • Prospective or retrospective? • The registrar wants to wait for an answer on the phone as he has to go to another ward

14. Query #3 • Prospective: • Indication for sodium valproate? • Proposed doses, duration etc. • Why ciprofloxacin? What infection is being treated? • Other drug therapy being taken?

15. Query #3 • Retrospective: • Establish why is the registrar ringing? • e.g. following a query from the patient, or because the 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 • Specialist Pharmacy Service • Fridge Database • Safety in Lactation • Dossette box stability • New Medicines Newsletters • Patent expiries • NICE Bites are available here too! • Patient.co.uk • NHS Choices • NHS Evidence • NEWT • Medline/EMBASE • Internet search engines • Pharmaceutical industry • Maudsley Prescribing Guidelines • Alerting/current awareness emails e.g. NICE, MHRA etc. • Clinical Key • Royal Pharmaceutical Society • Access to some books e.g. Pharmaceutical Excipients

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

21. Your Yellow Cards & Basic Enquiries • In the Introductory MI session we asked you to complete a Yellow Card and a basic enquiry form ...

22. 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

23. 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?

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

25. Question 4 • You receive a call while on-call, a nurse has accidentally given a patient’s bedtime dose of zopiclone twice. • One nurse gave a dose of zopiclone and went on break without signing, the nurse covering , gave another dose of zopiclone thinking it had not been given. • Where will you look? Link

26. 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

27. Question 6 • A GP calls and asks is there evidence to support the use of enteric coated aspirin to reduce GI side effects? • Where will you look? Link

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

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

30. Common resources used • BNF/BNFc • eMC • Martindale • DrugDex • AltMedDex • Stockley’s Drug Interactions • Natural Medicines Comprehensive database • CKS • TOXBASE • UpToDate • Specialist Pharmacy Service • Fridge Database • Safety in Lactation • Dossette box stability • New Medicines Newsletters • Patent expiries • Patient.co.uk • NHS Choices • NHS Evidence • NEWT • Medline/EMBASE • Internet search engines • Pharmaceutical industry • Maudsley Prescribing Guidelines • Alerting/current awareness emails e.g. NICE, MHRA etc. • Clinical Key • Royal Pharmaceutical Society • Access to some books e.g. Pharmaceutical Excipients

31. 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

32. 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

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

34. Tablet identification Time for some role-play! Volunteers please?

35. Communication skills

36. 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

37. 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”)

38. 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

39. 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

40. 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...”

41. Over to you!

42. Ethical dilemmas

43. 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.

44. 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

45. Ethical dilemma #1 • A woman says she has found some medicines in her son’s room. She reads the labels - lamivudine, zidovudine and saquinavir. • Can you tell her what they are for? • Would your answer be different if the call was from his wife?

46. Ethical dilemma – tablet ID • Has the caller been prescribed the medication for him or herself? (truthfully) • Gather as much info as possible before agreeing to answer • Always refuse if 3rd party unless overwhelming reasons (?dependent minors) • From 14yr, girls may be prescribed oral contraceptives without their parents’ knowledge. • Once over 13yr have a right to privacy • If under this age, is it in the child’s best interest? • Why doesn’t the parent know what it is? • Reasonable to suggest enquirer speaks directly to the owner of the drug

47. Ethical dilemma #2 • A police officer asks to see you at the Pharmacy Reception. He asks you to identify a tablet that was found outside a building that the police had raided and then they had chased and arrested a person. • How do you respond?

48. Ethical dilemmas - Police • Usually ID question • Fairness, what is the legitimate interest? • Is patient consent possible? • Can they send the request in writing if it is about a potential crime? • Is patient likely to suffer if others do not know what the tablets are? • BNF – best to use as in public domain

49. Ethical dilemma #3 • A technician asks you what the dose of phenobarbitone is. She has just taken a telephone call from a patient who wants to check what the toxic dose is so she doesn’t take too much, also what other things she shouldn’t take with it and how long it takes to act. • How do you respond?

50. Ethical dilemma #4 • A friend of yours rings you for a chat. She has just started going out with “a wonderful man” who had a kidney transplant 5 years ago and has been taking ‘anti-rejection’ meds since. He has told her that they have made him infertile so he will not be able to have children. • She wants to know if this is true as she really wants a family and, although he is wonderful, she will finish the relationship if there isn’t a future for it.