Medicines Information

1. Medicines Information for future pharmacists March 2017

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 vs. written) • Ethical dilemmas

3. Background Information

4. 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)?

5. Query #1 • 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/role/interest in this enquiry? • Establish indication if not clear. • How should I contact you? • When do you need an answer? • Prospective or retrospective?

6. 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?

7. Query #1 • Prospective: • What is being treated? • Severity of condition? • Which steroid? Dose? Frequency? Route? • What has been tried already? • Any co-morbidities? • Any other drug therapy being taken? • History of past pregnancies e.g. medication used in previous pregnancies

8. Query #2 • A junior doctor 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)?

9. Query #2 • 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/role/interest in this enquiry? • Establish indication if not clear. • How should I contact you? • When do you need an answer? • Prospective or retrospective? • At the end of the call, negotiate when you will provide an answer.

10. Query #2 • Prospective • Has mum been treated for depression before e.g. while pregnant? If so, with what and did it work? • Proposed dose of fluoxetine to be used? • Co-morbidities for mum? • Other drug therapy for either mum or baby? • Is the GP open to suggestions of possible safer alternatives (if found)?

11. Query #2 • Retrospective: • Establish why GP 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?

12. Query #3 • A registrar calls you and asks: “Is there an interaction between clarithromycin and citalopram?”

13. Query #3 • 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/role/interest in this enquiry? • Establish indication if not clear. • How should I contact you? • When do you need an answer? • Prospective or retrospective? • At the end of the call, negotiate when you will provide an answer.

14. Query #3 • Prospective: • Is citalopram a ‘long-term’ therapy and clarithromycin being prescribed ‘new’? • Proposed doses, duration etc. • Why clarithromycin? 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 • 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. BNF / BNFc • Access via www.medicinescomplete.com/mc • Apps also available to download • need NHS Athens password • Same content and layout as books • Monthly updates

19. 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

20. MicroMedex • Access via NHS Wales e-library http://www.wales.nhs.uk/ehl • Basic access with NHS Athens password • DrugDex / AltMedex • Martindale • Drug Interaction Checker • Trissel IV compatibility • Reprotox / TERIS / Shepard’s (MI only access)

21. 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

22. 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

23. Question 1 • You need to find some information to advise a GP regarding nifedipine-induced gingival hyperplasia. • Where will you look?

24. 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?

25. 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

26. 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?

27. 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

28. Complementary and Alternative Medicine • St John’s Wort (SJW) (Hypericum perforatum) • Active ingredients and mechanisms of actions unclear • Cochrane concludes that SJW is more effective than placebo in the treatment of mild to moderate depression, and is more effective and better tolerated than standard antidepressants • SJW is a potent inducer or hepatic CYP enzymes. • SJW significantly decreases plasma concentrations of digoxin, HIV medication, oral contraceptive pills, theophylline, clozapine, warfarin and many more. Also theoretical risks with anticonvulsant medication...

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

30. Question 4 • You are reviewing a guideline regarding people who misuse drugs etc. and need to determine the difference between a body-packer and a body-stuffer. • Where will you look? Link

31. 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

32. 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

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

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

35. 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

36. 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

37. 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

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

39. Tablet identification

40. Communication skills

41. 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

42. 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”)

43. 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

44. 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

45. 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...”

46. Over to you!

47. Ethical dilemmas

48. 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.

49. Ethical dilemmas – general points • There is no one “right” answer to most ethical dilemmas, but you should be able to justify what you do. • 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.

50. 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?