role preparation for nhs direct health information advisors handling medicines calls day 2 name...

Role Preparation for NHS Direct Health Information Advisors

Handling Medicines CallsDay 2

NameCentre Medicines Information Service

Role Preparation For NHS Direct HIAs: Handling Medicines Calls

Learning Outcomes

1. Have an overview of NHS Direct policies and roles of staff for Medicines Calls.

2. Have a baseline knowledge about medicines.

3. Have an overview of Community Pharmacy services and emergency supply of medicines.

4. Be able to handle medicines calls safely and effectively.


Learning Outcomes


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.


Morning Timetable

9.30 Introduction & Re-capAdverse effectsDrug interactions Workshop 4: Adverse effects & drug interactions

11.00 Tea breakMedicines in pregnancy Medicines when breast feedingWorkshop 5: Meds in pregnancy & breastfeeding

1.00 Lunch


Afternoon Timetable

1.45 Herbal medicinesWorkshop 6: Herbal Medicines

3.00 Tea breakWhere are the risks?What next?

4.00 Close


Adverse Effects

Account for 2-6% of hospital admissions

Type A predicted by mode of actionType B unpredictable

Changes in healthe.g. digoxin / renal function, warfarin / heart failure

Cross-sensitivity e.g. amoxicillin / cefadroxil

Unwanted effect that a drug has on a person


Recent Drug Alerts / Scares

Rimonabant Risk of suicide and depression

Co-proxamol High risk of death in overdose

Rofecoxib Withdrawn, risk MI and stroke

HRT Avoid longterm, risk breast cancer

Kava-Kava Withdrawn, hepatotoxicity

Cerivastatin Withdrawn, rhabdomyolysis


Incidence of Adverse Effects

Very common

Common

Uncommon

Rare

Very rare

10%

1% Risk of dying from cancer if smoke 20 a day for 30 years

0.1% Risk of being injured on the stairs in next 12 months

0.01% Risk of dying in an accident at home in next 12 months

up to 0.01%

Risk of being killed by lightening


Yellow Card Reporting Scheme

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

Both healthcare professionals and patients can report adverse effects


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.


When is a drug interaction clinically significant?

Increase toxicity

Warfarin Amiodarone

Increased risk of bleeding

Simvastatin Erythromycin

Increased risk of myopathy

Reduce efficacy

Ciclosporin Phenytoin

More ciclosporin needed

Thyroxine Rifampicin

More thyroxine needed


Drug interactions at the receptor

Nerve ending

Atenolol closes the bronchioles

Salbutamol opens the bronchioles

Receptor stimulated Receptor blocked

Nerve ending


Medicines that speed up the metabolism of other medicines

Blood level of the other medicine

will go down

Metabolic Enhancers

SmokingAlcohol

CarbamazepinePhenytoinRifampicin


Medicines that slow down the metabolism of other medicines

Metabolic Inhibitors

CimetidineCiprofloxacinErythromycinMetronidazole

Blood level of the other medicine

will go up


Narrow Therapeutic Range Drugs

CARBAMAZEPINE

CICLOSPORIN

DIGOXIN

LITHIUM

PHENYTOIN

THEOPHYLLINE

WARFARIN


Workshop 5: Adverse Effects & Drug Interactions


Tea Break


Morning Timetable

9.30 Introduction & Re-capAdverse effectsDrug interactions Workshop 4: Adverse effects & drug interactions

11.00 Tea breakMedicines in pregnancy Medicines when breast feedingWorkshop 5: Meds in pregnancy & breastfeeding

1.00 Lunch


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.


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.

Carbimazole Foetal goitre

Diethylstilboestrol Cancer of vagina and cervix

Isotretinoin Cranio-facial, CVS & CNS defects

NSAIDs Closure of ductus arteriosis

Warfarin Foetal warfarin syndrome


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)


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.


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.


Essential questions to ask

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?

Confirm no new or worsening symptoms

THE PERSON THE MEDICINE


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.


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).


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.


Essential questions to ask

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?

Confirm no new or worsening symptoms

THE PERSON THE MEDICINE


Workshop 6: Medicines during pregnancy & when Breastfeeding


Lunch Break


Afternoon Timetable



4.00 Close


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 conventional medicines


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.


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.


Public belief?

CONVENTIONAL MEDICINES

Artificial and toxic

Versus

HERBAL MEDICINES

Natural & Safe


Herbal medicines

3 types of product:(under review)

Licensed herbal medicine.

Herbal medicine exempt from licensing.

Food supplement.

May interact with conventional medicines


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.


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)


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)


Workshop 7: Herbal Medicines


Afternoon Timetable



4.00 Close


Where are the risks when handling a Medicines Call?

Clarify the question

Plan search strategy& research problem

Evaluate the information

Tailor the answer/advice

Refer to MIRecor

dall

stages


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.


Learning Outcomes

1. Have an overview of NHS Direct policies and roles of staff for Medicines Calls.

2. Have a baseline knowledge about medicines.

3. Have an overview of Community Pharmacy services and emergency supply of medicines.



Learning Outcomes


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.


What next?

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


The Medicines Call Review Tool

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.

Sections of Review Tool

ScreeningAnalysis & Critical Thinking

Information Sources Referral to UKMI

AnswerDocumentation

Traffic Light Scoring

Green: All points addressedAmber: Minor points missed

Red: Major points or several minor points missed

role preparation for nhs direct health information advisors handling medicines calls day 2 name...

Documents

nhs direct medicines

pregnancy medicines

nhs direct hias

handling medicines callswhen

emergency supply of

lunchrole preparation

rhabdomyolysisrole preparation

closerole preparation