Claudine Hughes

Chief Pharmacist, NMIC

Medicines should be prescribed only when they are necessary, and in all cases the benefit of administering the medicine should be considered in relation to the risk involved

Important to discuss the treatment options carefully with the patient to ensure that the patients is content to take the medicine as prescribed

Who can prescribe?Who can prescribe?

DoctorsDentistsVets

Future – Nurses, Pharmacists??

Influencing FactorsInfluencing Factors

Clinical status of the patientConsiderations of cost and value for moneyPressure from P’ceutical IndustryNew drug developmentPatient preferenceLocal formulary or prescribing policies

Questions to ask before Questions to ask before prescribing a drug?prescribing a drug?

What is it?

What is the drug used for?

How effective is this drug?

How safe is this drug?

Questions to ask before Questions to ask before prescribing a drug?prescribing a drug?

Who should not receive it?

Where did I hear about it?

What is it’s place in therapy?

Does this drug provide good value for money?

Legal Issues

S1A and S1B

Generic Prescribing

Information SupportInformation Support

BNF

Prescriber’s Guide

www.medicines.ie

Clinical PharmacyClinical Pharmacy

Comprehensive clinical pharmacy service in SJH

Daily ward visits by Clinical PharmacistsPrescription review includes: assessment of

legibility, dose & frequency, route of administration, drug-drug interactions

Source of informationAudit review

When and where?When and where?

Established 1994

DOH & C funded

Based in SJH

Staffed by both Pharmacists and Doctors. Activities overseen by multidisciplinary Advisory Committee

Enquiry ExamplesEnquiry Examples

Drug induced lupus – due to indapamide?

Choice of antidepressant in pregnancy?

Compatibility of morphine, midazolam and methotrimeprazine in a syringe driver?

What is Norvasc®?

Dose of doxcycline in patient with CrCl of 30ml/min?

Consequences of Poor Consequences of Poor PrescribingPrescribing

Medication Errors

Adverse Drug Effects

Medication ErrorsMedication Errors

“To err is human”, IOM 1999 – 25% treatment errors related to medication

Prescribing is an important area in terms of error occurrence

Types include: Wrong drug, dose, inadequate consideration of patient factors

Aminophylline Amitriptyline

Carbamazepine Carbimazole

Chlorpromazine Chlorpropamide

Daonil DanolLosec LasixRitonavir Retrovir

Inderal IpralTrental TegretolEpilim Epanutin

Adverse Drug ReactionsAdverse Drug Reactions

May occur due to lack of consideration for drug-drug interactions

Failure to dose adjust in patient’s with impaired organ function

Herbal MedicinesHerbal Medicines

................. Not all that is natural is

harmless

Why do people use herbal Why do people use herbal medicines?medicines?

Used in developing countries where cost of drugs is prohibitive, poor accessibility to drugs in rural areas, shortage of physicians

Perception that natural = safe

“More” ADRs reported with conventional medicines than herbal preparations

Why do people use herbal Why do people use herbal medicines?medicines?

Provide a sense of control, a mental comfort from taking action e.g. cancer, AIDS

Cultural & religious beliefs

Use differs by ethnic group, income, age & educational level

Problems Associated with Use Problems Associated with Use of Herbal Medicinesof Herbal Medicines

Lack of QC & standardisation

Adulteration with other plants, pharmaceutical drugs or heavy metals

Inappropriate use / misleading claims

Type A & B ADRs

Problems Associated with Use Problems Associated with Use of Herbal Medicinesof Herbal Medicines

Potential for drug interactions

Lack of knowledge re: interactions, ADRs

Ask me no questions – I’ll tell Ask me no questions – I’ll tell you no liesyou no lies

(why patients may not volunteer (why patients may not volunteer information)information)

Lack of awareness of the potential for adverse effects/interactions

Don’t consider product to be a medicineFear of censureBelief that the doctor/pharmacist doesn’t

know about alternative medicines

Sources of InformationSources of Information

Textbooks

Product Information from manufacturers

Published articles, studies, case reports

Regulatory authorities

St. John’s WortSt. John’s Wort

Safety of concurrent administration of SJW with prescription or OTC medications has not been established

Inducer of Cytochrome P450

Documented interactions with a number of prescription drugs

St. John’s WortSt. John’s Wort

With SSRIs, triptans - symptoms characteristic of serotonin syndrome

Theophylline (CYP1A2), cyclosporin (CYP3A4) and warfarin (CYP2C9) - reports of a reduction in the serum concs

With COC - reports of breakthrough bleeding - reduced efficacy?

Advice published by the IMB and CSM

Ginkgo BilobaGinkgo Biloba

ADRs - generally infrequent & transientGI upset, headaches, dizzinessContact with whole ginkgo plant associated

with severe allergic reactionsMay prolong bleeding time - caution in

patients taking anticoagulant/antiplatelet medication

EchinaceaEchinacea

ADRs - Relatively free of toxicity either topically or orally

Mild allergic reactions reported Serious allergic reactions reported in patients with

a Hx of asthma, atopy, allergic reactions Drug Interactions - Antagonises

immunosuppressants Increased bleeding time

In conclusion…In conclusion…

Interest in and information on alternative therapies is increasing

Lack of regulation – things are not always what they seem…

Information on use of these therapies must be specifically elicited from patients