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Pharmaceutical care of people with chronic obstructive pulmonary disease

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Pharmaceutical care of people with chronic obstructive pulmonary disease

page 2 Contentsofpack 3 Introduction 8 Pre-readingpaper 17 TeachingPlan 18 PharmaceuticalCareNeedsAssessmentTool 19 Aidememoire 22 Lecture:COPD

Course information

� pharmaceutical care of people with chronic obstructive pulmonary disease

Contents of Pack

Your pack contains:

• PharmaceuticalcareofpeoplewithCOPD–Courseinformation

• PharmaceuticalcareofpeoplewithCOPD–Courseactivities

• DVDpresentation-16:9PALformat. ThisDVDwillplayinalmostanyDVDplayer,and

anyPCorMacwithDVDplayingsoftware

ThispackwasbroughttogetherwiththehelpofDrAnneBoyter(SeniorLecturer,UniversityofStrathclyde).AlsospecialthankstotheWestofScotlandPharmacistsRespiratoryNetworkandinparticularMargaretMacDonald(NHSGreaterGlasgow&Clyde)whoreviewedthepack.

Whileeveryprecautionhasbeentakeninthepreparationofthesematerials,neitherNESnorexternalcontributorsshallhaveanyliabilitytoanypersonorentitywithrespecttoliability,lossordamagecausedorallegedtobecauseddirectlyorindirectlybytheinformationtherein.

Acknowledgements

Disclaimer

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Introduction

COPDisamajorbutunder-recognisedcauseofdeathanddisability.Globally,itisthefourthleadingcauseofdeathand,unlikeothermajorcausesofdeath,suchascardiovasculardisease,mortalityhasbeenrisingoverthepast40years.ConsultationswithgeneralpractitionersbypatientswithCOPDaresimilarinnumbertoasthmabutmorepatientswithCOPDwillbeadmittedtohospitalandtheywillstayinhospitalforonaverage7–10days.ThemortalityrateofCOPDisatleast14timesthatofasthma.

ThiscorecoursewillofferScottishpharmaciststheuniqueopportunitytobetrainedinaconsistentmanner.ItwillexplorehowpharmacistscancontributetothecareoftheirpatientswithCOPD,byapplyingtheprinciplesofpharmaceuticalcare.Thiswillbeinvaluabletrainingforcommunitypharmaciststohelppreparethemforthefuture.

ToupdatepharmacistsonthecurrentmanagementofCOPDandexplorewaystoimplementpharmaceuticalcareforthispatientgroupaspartofnormalworkingpractice.

Attheendofthesessionparticipantswillbeableto:

• definethecurrentstrategiesforthemanagementofpatientswithstableCOPDandexacerbationsofdisease

• identifypharmaceuticalcareissues,respondtosymptomsinpatientscenariosandidentifyappropriatemanagementsolutions

• explorehowtoimplementtheprinciplesofapharmaceuticalcareneedsassessmenttoolinpractice

JonesPW(2001)‘Healthstatusmanagementinchronicobstructivepulmonarydisease’,Thorax,56,880–887.

Pharmaceutical care of people with COPD

Objectives

Aim

Pre-course Reading


Chronicobstructivepulmonarydisease(COPD)isdefinedintheNICE/BTSguidelines1as“airflowobstructionthatisusuallyprogressive,notreversible,anddoesnotchangemarkedlyoverseveralmonths.”Itispredominantlycausedbysmoking.

COPDisthefifthlargestcauseofdeathindevelopedcountriesandmortalityismorethantentimesthatduetoasthma.Preventionisthemainlong-termstrategyfordealingwithCOPDandtheachievementofsmokingcessationisthemajorgoal.InestablishedCOPD,diseaseprogressioncanbedelayedbydrugtreatmentbutcannotbereversed.

EstimationofCOPDprevalenceisdifficultduetounderdiagnosisbutitaccountsforabout10%ofallacutehospitalmedicaladmissions.TheincidenceofCOPDinwomencontinuestorisebutithasreachedaplateauinmen.ItisestimatedthateachGPwillhaveabout200patientswithCOPDontheirlist;eachpatientwillvisittheirGP6or7timesayearandcostsabout£1600.

TreatmentforCOPDisoutlinedintheNICE/BTSguidelinewhichwillbecoveredinthelecture.Bothpharmacologicalandnon-pharmacologicalmethodsneedtobeemployedinthemultidisciplinarycareofthesepatientsastherapyisaimedatthemanagementofsymptomsratherthanareversalofthediseaseprocess.Therehavebeenadvancesindiseasemanagementoverrecentyears,particularlyintheuseoflong-actinganticholinergicssuchastiotropiumandtheuseofinhaledcombinationpreparationsoflong-actingbetaagonistsandcorticosteroids.

ThefivequestionswhichhavebeenshowntobeeffectiveinmonitoringCOPDmanagementare:

1 Hasyourtreatmentmadeadifferencetoyou?2 Isyourbreathingeasierinanyway?3 Canyoudosomethingsnowthatyoucouldn’tdobefore,ordo

thesamethingsbutfaster?4 Canyoudothesamethingsasbeforebutarenowlessbreathless

whenyoudothem?5 Hasyoursleepimproved?

ThesequestionshavebeensuggestedasameansofassessingthebenefitofanewtherapyinpatientswithCOPDandformpartof

General

Implementing the needs assessment


theNeedsAssessmenttoolforpeoplewithCOPD.WhilethereareanumberoftoolssuchastheChronicRespiratoryQuestionnaire(CRQ),theStGeorge’sRespiratoryQuestionnaire(SGRQ)andtheBreathingProblemQuestionnaire(BPQ)thesetendtobelengthyandcumbersometoadministerandmaynotbeindicativeofanindividual’sresponsetotherapy.Thesetoolsare,however,importantinthefieldofclinicalresearch.

Thefivequestionsabovecanbeusedtoassessifanewlyintroducedtherapyhasmadeadifferencetoanindividualpatientbasedonthepatient’sexampleswhenansweringthequestions.

SimilarlytheMRCdyspnoeascore(below)canbeusedtoevaluatethepatientsstatus.

MRC Dyspnoea Scale

TheMRCdyspnoeascaleisaquestionnairethatconsistsoffivestatementsaboutperceivedbreathlessness.

Grade1 Ionlygetbreathlesswithstrenuousexercise.Grade2 Igetshortofbreathwhenhurryingonthelevelorupa slighthill.Grade3 Iwalkslowerthanpeopleofthesameageonthelevel becauseofbreathlessnessorhavetostopforbreath whenwalkingatmyownpaceonthelevel.Grade4 Istopforbreathafterwalking100yardsorafterafew minutesonthelevel.Grade5 Iamtoobreathlesstoleavethehouse.


ChronicObstructivePulmonaryDisease(2004)‘Nationalclinicalguidelineonmanagementofchronicobstructivepulmonarydiseaseinadultsinprimaryandsecondarycare’,Thorax,59(suppl1)1–232

Thisdocumentislengthybutdoescontainausefulsummaryoftheguideline.ThesummaryandtheguidelinecanbeobtainedviatheThoraxwebsitehttp://thorax.bmj.com/content/vol59/suppl_1/

ABCofCOPD–availablefromBMJpublications£17.99butalsoavailableasaseriesofarticlesintheBMJ.

1 DevereauxG(2006)‘ABCofchronicobstructivepulmonarydisease.Definition,epidemiologyandriskfactors’BMJ,332:1142–1144

2 MacNeeW(2006)‘ABCofchronicobstructivepulmonarydisease.Pathology,pathogenesis,andpathophysiology’BMJ,332:1202-1204

3 CurrieGP,LeggeJS(2006)‘ABCofchronicobstructivepulmonarydisease.Diagnosis’BMJ,332:1261–1263

4 SrivastavaP,CurrieGP,BrittonJ(2006)‘ABCofchronicobstructivepulmonarydisease.Smokingcessation’BMJ,332:1324–1326

5 CurrieGP,DouglasJG(2006)‘ABCofchronicobstructivepulmonarydisease.Non-pharmacologicalmanagement’BMJ,332:1379–1381

6 CurrieGP,LipworthBJ(2006)‘ABCofchronicobstructivepulmonarydisease.Pharmacologicalmanagement–inhaledtreatment’BMJ,332:1439–1441

7 CurrieGP,LeeDKC,LipworthBJ(2006)‘ABCofchronicobstructivepulmonarydisease.Pharmacologicalmanagement–oraltreatment’BMJ,332:1497–1499

8 CurrieGP,DouglasJG(2006)‘ABCofchronicobstructivepulmonarydisease.Oxygenandinhalers’BMJ,333:34–36

9 CurrieGP,WedzichaJA(2006)‘ABCofchronicobstructivepulmonarydisease.Acuteexacerbations’BMJ,333:87–89

10 ChristieG,CurrieGP,PlantP(2006)ABCofchronicobstructivepulmonarydisease.Ventilatorysupport.BMJ,333:138–140

11 FreemanD,PriceD(2006)‘ABCofchronicobstructivepulmonarydisease.Primarycareandpalliativecare’BMJ,333:188–190

12 BarnesPJ(2006)‘ABCofchronicobstructivepulmonarydisease.Futuretreatments’BMJ,333:246–248

13 McIvorA,LittleP(2007)‘10-minuteconsultation.Chronicobstructivepulmonarydisease’BMJ,334:798

Other Useful Reading


1 ChronicObstructivePulmonaryDisease(2004)‘Nationalclinicalguidelineonmanagementofchronicobstructivepulmonarydiseaseinadultsinprimaryandsecondarycare’,Thorax,59(suppl1)1–232

BritishLungFoundation–http://www.lunguk.org/ChestHeartandStrokeScotland–http://www.chss.org.uk/BritishThoracicSociety–http://www.brit-thoracic.org.uk/GlobalInitiativeforChronicObstructiveLungDisease–http://www.goldcopd.com/EducationforHealthhasarespiratorycoursethatcanprogresstodegreelevel.Formoredetailscheckhttp://www.educationforhealth.org.uk

References

Useful contacts


JonesPW.Healthstatusmanagementinchronicobstructivepulmonarydisease.Thorax2001;56:880–887

10 pharmaceutical care of people with chronic obstructive pulmonary disease

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1� pharmaceutical care of people with chronic obstructive pulmonary disease

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10mins Introductiontotheevening

50mins Lecture

10mins Comfortbreak

80mins Workshop

Splitthegroupintosmallergroupsofabout7or8

Thereare4casesbutinthetimeitisprobablyonlypossibletocoverthreeofthese.Thethreecasestobecoveredshouldbechoseninconsultationwiththelocaltutors.Ifspirometersareavailablethendiscussionofcase1shouldincludeallowingparticipantstomeasuretheirownlungfunction.

Eachofthegroupsshouldbeencouragedtocoverallthecases;thisshouldtakeabout15to20minutesforeachcaseandthenabout10to20minutesforgeneralfeedbacktocoverthemaindiscussionpointsforeachcase.

COPD teaching plan

Pharmaceutical Care Needs Assessment Chronic Obstructive Pulmonary Disease

Name Doctor’s name

Date of birth or CHI no. Date

Can you tell me what medical condition(s) you have?

dose frequency no ordered monthlyWhat is/are the name(s) of the medication you take for your condition(s) and how do you take it/them?

yes no

Do you ever forget or choose not to take your medication?If yes, how often – weekly/monthly?

Do you know what to do if you have missed a dose of your medication?

What, if any, side-effects do you experience from your medication?

yes no Do you feel that your medication is controlling your symptoms or have you noticed any changes since you started taking your medication? Do you know the trigger signs?

Do you have a regular check/blood test/review? Can you tell me when that was, and the outcome?

Would you like any information/advice on anything about your condition/medication/health promotion areas?

Do you smoke? If yes how many cigarettes and for how long?

Specific COPD questions yes noHas your treatment made a difference to you?Is your breathing easier in any way?Can you do some things now that you couldn’t do before or do the same things but faster?Can you do the same things as before but are now less breathless when you do them?Has your sleep improved?Please give me an example

Issue or action

Understanding Compliance Other Effectiveness Health/self help Safety Referral

Note any follow up action required and any outcome

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Aide memoire - chronic obstructive pulmonary disease

1. Can you tell me what medical condition(s) you have? Thishelpstoclarifytheirunderstandingoftheircondition(s).Length

ofdiagnosiscanbeimportant.Peopleareprovidedwithlotsofsupportandinformationatinitialdiagnosis–theamountofinformationandsupportreceivedatdiagnosiswillvary,alsotheymayormaynotbeattendingappropriateclinics.Overtimepeoplecanforgetkeyinformationorthemessagesmaychangeovertime.

Action Noteanswerandofferpatientgeneralinformationonconditions.

2. What is/are the name(s) of the medication you take for your condition(s) and how do you take it/them?

Checkwithprescriptionorpatientmedicationrecords.Confirmthatthepatientistakingthemedicationasinstructedontheprescriptionwithanyappropriatecounsellinginstructions,e.g.swallowedwhole.

Action Notehowpersontakesmedicationandofferappropriateadvice.

3. Do you ever forget or choose not to take your medication? If yes, how often – weekly/monthly?

Clarifywhichdrugsaremissed,whenandwhy.Action Offerappropriateverbaladvicedependingonresponse.

4. Do you know what to do if you have missed a dose of your medication?

Documentresponse.Action Offerappropriateverbaladvicedependingonresponse.

5. What, if any, side effects do you think you are experiencing from your medication?

Adverseeffectsarecommon;mostaredose-relatedandpredictable.Idiosyncraticadverseeffectsarepotentiallydangerousandusuallyoccurinthefirstweeksoftreatment.Somepeopleerroneouslylinkmedicationtoadverseeffectsandthiscanaffecttheiradherencetotheirregimen.Itispossibletomanagesomeadverseeffects.

Action Noteanyadverseeffectsandconfirmthattheyareasaresultoftheir medicationandreassurepatientaccordingly.

Pharmaceutical Care Needs Assessment Chronic Obstructive Pulmonary Disease

�0 pharmaceutical care of people with chronic obstructive pulmonary disease

6. Do you feel that your medication is controlling your symptoms or have you noticed any changes since you started taking your medication? Do you know the trigger signs?

Documentresponse.Considerandofferappropriateadvice. Action Offerappropriateverbaladvicedependingonresponse.

7. Do you have a regular check/blood test/review? Can you tell me when that was, and the outcome? Documentresponse.Considerandofferappropriateadvice.Action Offerappropriateverbaladvicedependingonresponse.

8. Would you like any information on anything about your condition/ medication/health promotion areas? Thishelpstoidentifyanyself-helporhealthissues.Action Offeradviceandsupportonhowthepersoncanmanagetheir lifestylemoreeffectivelyorsignpostthemtootherorganisations. Offergeneralhealthyeatingadviceasappropriate.

9. Do you smoke? How many cigarettes do you smoke and how long have you smoked Smokingexacerbatesrespiratoryconditionsbycausingdamageto theairwaysandincreasingtheriskofanattack.Allpatientsshould beencouragedtostopsmoking.Identifywhatstagetheyareatinthe “cycleofchange”model.InpatientssuspectedofhavingCOPD,it isimportanttohaveasmokinghistoryasthismayhelptoconfirmthe diagnosis. Action Offerappropriatesupportorrefertolocalsupportagencydepending onlocalarrangements.

Thefollowingquestionsrelatetothequalityoflifeimprovementsthat canbeseenifthepatientisrespondingtotreatment.Patientswith COPDwillnoticeimprovementsintheirqualityofliferather thanchangesinlungfunctionwhichmaybesubtleornotrecorded. Whenaskingpatientsaboutthechangesthatfollow,ensurethatthey giveanexampleofhowthechangehasaffectedthem.Action Ifthechangeisthoughttobesignificantthenthepatientshould continueonthetherapy.Ifachangeintherapyhasnotleadtoa significantchangeintheseparametersthenthepatientshouldbe discussedwiththeirGP.

10. Has your treatment made a difference?

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11. Is your breathing easier in any way?

12. Can you do some things now that couldn’t do at all before or do the same things but faster?

13. Can you do the same things as before but are now less breathless when you do them?

14. Has your sleep improved?

Thisaidememoireisforguidanceandpharmacistsshouldusetheir professionaljudgementatalltimes.

�� pharmaceutical care of people with chronic obstructive pulmonary disease

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