Role Preparation for NHS Direct Health Information Advisors Handling Medicines Calls Day 2

1. Role Preparation for NHS Direct Health Information AdvisorsHandling Medicines CallsDay 2 Name Centre Medicines Information Service

2. Learning Outcomes • Have an overview of NHS Direct policies and roles of staff for Medicines Calls. • Have a baseline knowledge about medicines. • Have an overview of Community Pharmacy services and emergency supply of medicines. • Be able to handle medicines calls safely and effectively.

3. Learning Outcomes • Be able to handle medicines calls safely and effectively. • Know what background information is needed to clarify the question and minimise the risks when advising the caller. • Be able to navigate the key medicines information sources. • Be able to interpret information about medicines and turn it into appropriate advice. • Know when and how to refer medicines calls to UKMI. • Be able to use the NHS Direct Medicines Algorithm.

4. Morning Timetable 9.30 Introduction & Re-cap Adverse effects Drug interactions Workshop 4: Adverse effects & drug interactions 11.00 Tea break Medicines in pregnancy Medicines when breast feeding Workshop 5: Meds in pregnancy & breastfeeding 1.00 Lunch

5. Afternoon Timetable 1.45 Herbal medicines Workshop 6: Herbal Medicines 3.00 Tea break Where are the risks? What next? 4.00 Close

6. Adverse Effects • Account for 2-6% of hospital admissions • Type A predicted by mode of action Type B unpredictable • Changes in health e.g. digoxin / renal function, warfarin / heart failure • Cross-sensitivity e.g. amoxicillin / cefadroxil Unwanted effect that a drug has on a person

7. Recent Drug Alerts / Scares

8. Incidence of Adverse Effects

9. NEWER MEDICINES & VACCINES () All ADRs even if Not certain that the medicine has caused it Reaction well known Other drugs at same time ESTABLISHED MEDICINES & VACCINES All serious ADRs Fatal, life threatening or disabling Prolonged hospital stay Even if well known Yellow Card Reporting Scheme Both healthcare professionals and patients can report adverse effects

10. Drug Interactions • One drug modifies the effect(s) of a second drug. • More likely if taking several medicines. • Many types of interaction. • May or may not be clinically significant.

11. When is a drug interaction clinically significant?

12. Salbutamolopens the bronchioles Receptor stimulated Drug interactions at the receptor Atenolol closes the bronchioles Nerve ending Nerve ending Receptor blocked

13. Blood level of the other medicine will go down Metabolic Enhancers Smoking Alcohol Carbamazepine Phenytoin Rifampicin Medicines that speed up the metabolism of other medicines

14. Metabolic Inhibitors Cimetidine Ciprofloxacin Erythromycin Metronidazole Blood level of the other medicine will go up Medicines that slow down the metabolism of other medicines

15. Narrow Therapeutic Range Drugs CARBAMAZEPINE CICLOSPORIN DIGOXIN LITHIUM PHENYTOIN THEOPHYLLINE WARFARIN

16. Workshop 5: Adverse Effects & Drug Interactions

17. Tea Break

18. Morning Timetable 9.30 Introduction & Re-cap Adverse effects Drug interactions Workshop 4: Adverse effects & drug interactions 11.00 Tea break Medicines in pregnancy Medicines when breast feeding Workshop 5: Meds in pregnancy & breastfeeding 1.00 Lunch

19. Medicines during pregnancy • Increased public awareness and concern since the thalidomide tragedy. • 1 in 40 babies have a major birth defect of which 1% due to exposure to medicines in-utero. • Almost all medicines cross the placenta and have the potential to cause harm. • Up to 50% pregnancies are unplanned. • Medicines can not always be avoided.

20. Teratogen Any agent which given in pregnancy causes or contributes to either malformation, abnormal physiological function or mental development of the foetus or child after birth.

21. Timing Of Exposure • 1st Trimester (weeks 1- 12) • Up to 2 weeks, “all or nothing” effect • Weeks 3-8, major organ systems being formed • 2nd Trimester (4th – 6th month) • Cerebellum & urogential system still forming • Growth and functional development • 3rd Trimester (6th – 9th month) • Specific effects e.g. NSAIDs (pulmonary hypertension) B-blockers (hypoglycaemia)

22. Identification Of Teratogens • Many possible causes for a birth defect (genetic, physiological, nutrition, medicines, pollutants). • Extremely difficult to determine whether or not a particular agent is a teratogen. • Clinical trials of medicines in pregnant women is usually unethical. • Difficult to extrapolate findings in animal studies to a human pregnancy.

23. General Advice • Consider non-drug treatments. • Avoid all medicines in the 1st trimester if possible. • Assess benefit/risk ratio for both mother & infant. • Avoid new medicines as usually more experience with well-established ones. • Use the lowest effective dose for as short a time as possible.

24. Name, dose, frequency? Who is it for? What prescribed for? Why asking? Other medicines? Name, dose, frequency? Age? Disease states? Allergies? Pregnant: no. of weeks, going well, medicine taken already? Breastfeeding: baby age, term/pre-term, well/unwell, medicine taken already? Essential questions to ask Confirm no new or worsening symptoms THE PERSON THE MEDICINE

26. Advice on infant feeding • Breast milk is the best form of nutrition for infants. • Exclusive breastfeeding for the first 6 months. • Breastfeeding (and/or formula milk) with appropriate solid food after 6 months, ideally for up to 1 year. • Mothers unable (or choose not) to breastfeed should be helped to optimise infant feeding.

27. How much of the medicine reaches the baby? Depends on: • Plasma concentration of medicine in the mother. • Characteristics of the medicine. • Amount of milk taken by baby per feed (approx 150mL/kg).

28. General advice • Avoid unnecessary use of medicines. • Assess risk / benefit for mother and baby. • Higher risk for premature babies. • Check if medicine licensed for babies. • Avoid long-acting and black-triangle medicines. • Try to time feed to avoids plasma peaks. • Monitor baby for adverse effects.

29. Name, dose, frequency? Who is it for? What prescribed for? Why asking? Other medicines? Name, dose, frequency? Age? Disease states? Allergies? Pregnant: no. of weeks, going well, medicine taken already? Breastfeeding: baby age, term/pre-term, well/unwell, medicine taken already? Essential questions to ask Confirm no new or worsening symptoms THE PERSON THE MEDICINE

30. Workshop 6: Medicines during pregnancy & when Breastfeeding

31. Lunch Break

32. Afternoon Timetable 1.45 Herbal medicines Workshop 6: Herbal Medicines 3.00 Tea break Where are the risks? What next? 4.00 Close

33. Homeopathic medicines • More dilute means greater potency. • Potency expressed in ‘c’ - 6c means diluted 1:100 for 6 times. • Inactivated by strong flavours, light and radiation. Do not interact with conventionalmedicines

34. Plants as medicines • 40% of all pharmaceuticals in industrialised countries are plant based e.g. Digoxin, Taxols, Vincristine. • 2% of prescriptions in USA are for medicines with natural ingredients. • Over 80% of the world rely on plant based remedies.

35. Herbal Medicine • Philosophy is to treat the individual rather than the diagnosed disease. • Whole plant extracts. • Often non-standardised and so active ingredients may vary • Where grown (sunshine, rainfall, temperature, soil). • Storage conditions. • Combine herbs.

36. Public belief? CONVENTIONAL MEDICINES Artificial and toxic Versus HERBAL MEDICINES Natural & Safe

37. Herbal medicines May interact with conventional medicines 3 types of product: (under review) • Licensed herbal medicine. • Herbal medicine exempt from licensing. • Food supplement.

38. Efficacy • Evidence variable – very few systematic reviews or meta analyses. • Herbs contain a variety of ingredients • Which ones are active? • Are they synergistic? • Problems with standardisation between preparations. • Hampered by safety and quality issues.

39. Risks • Delay conventional medical advice • Inherent toxicity • Kava kava (over 70 cases liver damage) • Ginseng (teratogenic in rats) • Ephedra (deaths in USA) • Aristolochia / Mu tong (kidney failure, cancer) • Mistaken identity • Digitalis for plantain (1997 arrhythmias) • Japanese for Chinese Star Anise (2001 fits) • Aristolochia for Stephania (1993 renal failure)

40. Risks • Adulteration • Contamination: bacteria, pesticides, heavy metals. • Contamination: prescription medicines • Glibenclamide (Xiaoke Wan in New Zealand) • Fenfluramine (Qian Er in UK) • Sildenafil (Hua Fo) • Steroids (Yibishu ointment in UK) • Drug interactions • St John’s Wort (warfarin, COCs, digoxin, phenytoin, zidovudine and others) • Cranberry (warfarin)

41. Workshop 7: Herbal Medicines

42. Afternoon Timetable 1.45 Herbal medicines Workshop 6: Herbal Medicines 3.00 Tea break Where are the risks? What next? 4.00 Close

43. Where are the risks when handling a Medicines Call? Record all stages Clarify the question Refer to MI Plan search strategy & research problem Evaluate the information Tailor the answer/advice

44. Where are the risks when handling medicines calls? • Missed symptoms. • Misunderstanding what the caller said. • Incomplete background information. • Omitting relevant information sources. • Searching / interpretation of information sources. • Caller doesn’t understand the answer. • Working outside your level of competency.

45. Learning Outcomes • Have an overview of NHS Direct policies and roles of staff for Medicines Calls. • Have a baseline knowledge about medicines. • Have an overview of Community Pharmacy services and emergency supply of medicines. • Be able to handle medicines calls safely and effectively.

46. Learning Outcomes • Be able to handle medicines calls safely and effectively. • Know what background information is needed to clarify the question and minimise the risks when advising the caller. • Be able to navigate the key medicines information sources. • Be able to interpret information about medicines and turn it into appropriate advice. • Know when and how to refer medicines calls to UKMI. • Be able to use the NHS Direct Medicines Algorithm.

47. TRAINING Medicines Call Algorithm Hormonal contraception ASSESSMENT 3 mock scenarios assessed by UKMI before taking live calls 3 live calls assessed by NHSD and 2 of these by UKMI before independent practice What next?

48. Add on to HIA Call review tool if call about medicines. 6 sections based on the key steps involved when handling a medicines call. Each section has a checklist of points to be addressed. The Medicines Call Review Tool