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Medicines Information. Useful sources Basic enquiry answering. October 2017. Session aims. Increase awareness of what questions to ask an enquirer Have practical experience using some resources which will be useful throughout the pre-registration year
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Medicines Information Useful sources Basic enquiry answering October 2017
Session aims • Increase awareness of what questions to ask an enquirer • Have practical experience using some resources which will be useful throughout the pre-registration year • Increase awareness of the Medicines Information (MI) services • UK • Wales
Source of enquiries • GP/hospital doctor • Nurses – community/hospital • Pharmacy colleagues • Other healthcare professionals • Patient • Carer • Own knowledge/CPD
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)?
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.
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?
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?
Query #2 • A nurse 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)?
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.
Query #2 • Prospective • Was baby born at term & is baby healthy & of normal weight for its age? • Has mum been treated for depression before e.g. while pregnant? If so with what & did it work? • Proposed dose of fluoxetine to be used? • Co-morbidities for mum? • Other drug therapy for either mum or baby? • Is prescriber open to suggestions of possible safer alternatives (if found)?
Query #2 • Retrospective: • Establish why nurse 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?
Query #3 • A GP calls you and asks: “Is their an interaction between clarithromycin and citalopram?”
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.
Query #3 • Prospective: • Is citalopram a ‘long-term’ therapy & clarithromycin being prescribed ‘new’? • Proposed doses, duration etc. • What infection is being treated? (Why clarithromycin?) • Other drug therapy being taken?
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.?
Enquiry for you... • Patient on the Medical Admissions Unit • admitted with GI bleed • Consultant suggests may be due to citalopram • Junior Dr wants more information on this AE • What further information do you need?
Further background information • Enquirer name & how to contact them? • Patient details? • (We know the query is retrospective) • What was the indication & the dose of citalopram? • When was it started/has the dose recently been increased? • Co-morbidities/risk factors? • Taking any other medication? • When is the answer needed?
So, the enquiry really is... • Mrs EW is an 83-year old lady who has been admitted to hospital with a GI bleed. The consultant has suggested her citalopram 40mg daily may be a possible cause (she has taken this for 2 months & takes no other regular medication) & has no risk factors for a GI bleed. No relevant PMH.. • The junior doctor (Dr Jones) is not familiar with this adverse effect of citalopram and requests additional information on this as a possible cause of the GI bleed.
eMC • Access via www.medicines.org.uk/emc • SPCs and PILs • Only for products registered with the ABPI (members supply ~90% of UK medicines) • Free access – no login required • Useful links, e.g. X-PIL
BNF / BNFc • Access via www.medicinescomplete.com/mc • Apps also available to download • Same content and layout as books • Monthly updates
Medicines Complete • Access via www.medicinescomplete.com/mc • Subscription required • AHFS • Stockley’s Drug Interactions • Stockley’s Herbal Medicines Interactions • Handbook of Drug Administration via enteral feeding tubes • Trissel’s Handbook on Injectable Drugs • Herbal Medicines • Dietary Supplements
MicroMedex • Access via NHS Wales elibrary http://www.wales.nhs.uk/ehl • Basic access with NHS Athens password • Detailed drug monographs (including some complementary medicines) • Quick Answers/In-depth Answers • Martindale • Drug Interaction Checker • Trissel IV compatibility • Reprotox / TERIS / Shepard’s (MI only access)
SPS website • Medicines Use & Safety, Procurement, Quality Assurance, Technical Services & UKMi • Access via www.sps.nhs.uk • Fridge stability database • Drugs in lactation database • UKMi Q&As • Medicines compliance aid database
NICE Evidence Search • https://www.evidence.nhs.uk/ • Evidence on treatments, medicines and safety • Can search the latest key medicines and prescribing information in one place • Enter a term into the search bar • Use filters to narrow down search results • Register for email updates
Yellow Card Scheme • Run by the MHRA and Commission on Human Medicines • Introduced in 1964 after thalidomide tragedy • Spontaneous reports of suspected ADRs • Acts as an early warning system to identify ADRs and risk factors • Over 780,000 confidential reports received in UK www.yellowcardwales.org
Why report ADRs? • Important role in patient safety • Allows continual safety monitoring of drugs • old and new • New drugs – lack of experience on ADRs • exposure in ~1500 people only for short duration • unlikely to detect frequency <1/500 or long latency • lack of experience in special patient groups • elderly, children, pregnancy, >1 disease / drug • Detect rare adverse effects www.yellowcardwales.org
What to report? Report all suspected ADRs for: new drugs (marked ▼) – even if not serious • The black triangle indicates a medicine is being intensively monitored. • It is assigned to :- • new drugs • new combinations of drugs • novel routes or delivery systems for drugs • significant new indications for drugs
What to report? Report all serious suspected adverse drug reactions to established drugs (adults and children) • Fatal • Life-threatening • Disabling or incapacitating • Result in or prolong hospitalisation • Congenital abnormalities • Medically significant
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
Examples of ADRs identified by Yellow Card Scheme • Domperidone – risk of cardiac SEs • use now restricted to N&V indication • limited duration • Mirabegron – risk of severe hypertension • Strontium ranelate – risk of cardiac SEs • C/I in those with cardiac problems • use restricted to severe osteoporosis, last resort • Risk of switching between branded and generic anti-epileptics www.yellowcardwales.org
Our enquiry • Should a yellow card be completed regarding our patient with the GI bleed?
Applying theory to practice • Complete a yellow card and submit to MHRA OR • Document a basic enquiry (e.g. adverse effects/drug interactions/drug dosing in renal impairment) • Bring a copy of the yellow card/enquiry to next WCPPE MI session and be prepared to discuss it
Medicines Information Service • A service that • supports the safe, effective and efficient use of medicines by the provision of evidence-based information and advice on their therapeutic use • UKMi • Local centres • Regional centres • Specialist centres • Virtual national network
Who uses MI services in Wales? • Total enquiries taken in 2016 = 4,585
What do they ask? • Total enquiries taken in 2016 = 4,585
Reflective learning • In your own time, consider the following points: • What have I learnt today? • What do I need clarification on? • How am I going to go about clarifying that?
