Medicines Information Enquiry answering guidelines These guidelines draw together current UKMi guidance and resources and provide a guide to answering enquiries categorised by type. They can be easily adapted to include local resources. The document can be used for training or as a helpful reminder for more experienced medicines information. For all enquiries you need to know: 1. The enquirer. 2. Contact details. 3. Urgency of enquiry. 4. Purpose of enquiry e.g. patient specific, project. 5. What sources already been used (NB. Try to assess enquirer’s experience of searching more complicated resources as you may feel you need to do extra research). Each monograph is divided into the following sections: 1. Background information – pointers to information that may be required. 2. Resources. a. First-line resources, including: i. In-house past enquiries. Use your judgement to decide if an enquiry is too old to be relevant. For suggested keywords to search for, see the end of each monograph. ii. UKMi Medicines Q&As Look for these early in your search; a relevant Q&A can save you a lot of work. b. Local resources e.g. contact details of experts, relevant departments, and policies. 3. Answering the enquiry – useful pointers to factors that should be considered. 4. Keyword suggestions for future enquiry retrieval.
Essential resource list These guidelines should be used in conjunction with the UKMi Essential Resources list. This lists resources for purchase and resources with free access for NHS Medicines Information Services and is accessed via: www.ukmi.nhs.uk/activities/clinicalGovernance/default.asp?pageRef=4
Risk Management No single source is totally comprehensive or completely up-to-date in all respects. Information about risks associated with some resources used by UKMi can be accessed via: www.ukmi.nhs.uk/filestore/ukmiacg/Risk-CommonInformationSources2.doc
ADMINISTRATION OF MEDICINES...... 2 ADVERSE DRUG REACTIONS...... 5 DRUGS IN BREASTFEEDING...... 8 COMPATIBILITY OF INTRAVENOUS DRUGS 11 COMPATIBILITY OF SUBCUTANEOUS DRUGS 13 COMPLEMENTARY MEDICINE...... 15 CONTRACEPTION (HORMONAL)...... 18 CYTOTOXIC MEDICINES...... 22 DENTAL...... 23 DRUG USE IN HEPATIC IMPAIRMENT.....26 PHARMACEUTICAL IDENTIFICATION...... 29 IMMUNISATION...... 31 INTERACTIONS...... 33
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NEW PRODUCTS...... 35 PAEDIATRICS...... 37 PALLIATIVE CARE...... 40 PHARMACEUTICAL...... 42 PHARMACOKINETICS...... 45 POISONING OR OVERDOSE...... 48 PREGNANCY...... 49 DRUG USE IN PSYCHIATRY...... 51 RENAL IMPAIRMENT...... 53 MEDICINES IN SPORT...... 57 SUBSTANCE MISUSE...... 59 TRAVEL MEDICINE...... 61 WOUND CARE...... 66
Publication date: Feb 11, Revision date: Jan 13 Administration of medicines Background information These guidelines are for situations where patients are unable to tolerate oral medicines and other options need to be considered e.g. swallowing difficulties, patients who are nil-by-mouth (NBM) etc. Have any other medicines or routes of administration been considered? Are there any restrictions on the choice of administration route? For example, patients with diarrhoea may not be able to use rectal preparations. Patients with burns, eczema, excess hair or very sensitive skin conditions may not be able to use transdermal preparations. Patients with low muscle mass will not be able to have intramuscular injections. Patients with increased bleeding risk will not be able to have subcutaneous or intramuscular injections. What other routes are available? For example, does the patient have a venflon inserted; do they have an enteral feeding tube in situ? Is a subcutaneous pump being used?
Nil-by-mouth (NBM) prior to surgery: What medicines and doses is the patient taking? How long is the patient likely to be NBM? Have any other formulations been considered? What medicines and doses does the patient need? Can any be suspended temporarily?
Ocular administration: If the question is about order or administration of eye drops - what are the names and doses of the medicines? If the question is about number of bottles of eye drops to dispense – who long will the patient be using the eye drops for? Are the drops to go into one or both eyes? What is the dosage frequency?
Nebulised administration: What medicines are to be nebulised?
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What are the doses and frequency of administration? What type of nebuliser is being used?
Swallowing difficulties: What medicines and doses is the patient taking? Is their swallowing expected to improve? If so when is this likely? Have any other methods of administration been considered or tried? E.g. transdermal patches. Is the patient able to swallow thin liquids or are thickened fluids or sip feeds being used?
Enteral feeding tube administration: What type of feeding tube does the patient have e.g. Nasogastric, percutaneous endoscopic gastrostomy or jejunostomy? What feeding regime is being used? Which feed is being given? Consider interactions between medicines and enteral feeds. Have any other methods of administration been considered or tried? E.g. transdermal, rectal. What medicines and doses is the patient taking? For enquiries that relate to administration of medicines to children, please refer to the ‘Paediatrics’ monograph. For enquiries that relate to parenteral administration refer to Compatibility of Intravenous Drugs’ and ‘Compatibility of Subcutaneous Drugs’ monographs.
Resources Source Notes First-line resources In-house past enquiries. Relevant Medicines Q&As via www.nelm.nhs.uk British National See chapter 15.1 ‘surgery and long term medication’. Formulary, www.bnf.org Electronic Medicines The Summary of Product Characteristics has details of administration of Compendium, nebuliser solution and information about combining solutions in the nebuliser www.medicines.org.uk/em chamber. c The Summary of Product Characteristics for a tablet and capsule preparation may state if it can be crushed or opened. Moorfields Eye Hospital Contains clinical guidelines and dosing information. Lists the preparations NHS Foundation Trust available from Moorfields Eye Hospital. Provides a table for determining the Pharmacists Handbook. number of bottles of eye drops to be dispensed according to the dose 2006. prescribed. Hand book of Drug Administration via Enteral Feeding Tubes. White R and Bradnam V. The NEWT Guidelines. Useful for advice about patients with swallowing difficulties and those with Smyth J. North East feeding tubes. Wales NHS Trust. Additional resources (tailor to local use/availability)
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Source Notes Rosemont Rosemont are specialists in oral liquid medicines for people who have Pharmaceuticals website, swallowing difficulties (dysphagia). The website lists the liquid formulations they http://www.rosemontphar make. ma.com www.swallowingdifficulties This website has been produced by Dr David Wright at the University of East .com Anglia. It is funded by Rosemont Pharmaceuticals. The website contains information for patients with swallowing difficulties, guidelines for healthcare professional and a list of liquid and non-oral alternatives. British Association of BAPEN has produced several useful documents which advise on drug Parenteral and Enteral administration via enteral feeding tubes – a patient guide, a GP/Community Nutrition (BAPEN) Pharmacy guide and an A3 poster including a step-by-step guide for safe drug www.bapen.org.uk/res_dr administration, legal implications and potential drug interactions. ugs.html Local resources
Answering the enquiry Have any other methods of administration been considered or tried? E.g. transdermal, rectal. The BNF and SPCs are a good place to start for most straightforward administration questions. Crushing tablets or opening capsules renders them unlicensed. Consider if there is a licensed liquid or dispersible formulation available. Consider any potential interactions between medicines being administered via a feeding tube and feeds. Is there an alternative drug that can be used or administered more easily?
Keywords: drug name, TUBE FEEDING, DRUG ADMINISTRATION, SURGERY.
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Adverse Drug Reactions Background information Retrospective enquiries (i.e. suspected ADR has already occurred) Establish patient details, including age, sex etc. What is the indication for the drug and any relevant medical history (e.g. renal function)? What is the current and previous medical history if relevant, including risk factors for the ADR? Is there a history of adverse drug reactions or allergies? List current drug therapy, including OTC, alternative therapies and drugs of abuse whenever possible, plus any medication taken within the last 3 months. What is the timing of the reaction in relation to start or dose increase of the suspected drug? Obtain a full description of the signs and symptoms of the reaction; clarify reactions such as 'rash', 'abnormal liver function tests (LFTs)', 'aching all over'. Has the suspected drug been stopped? How has the patient been managed so far? Has rechallenge, deliberate or inadvertent, been undertaken? Did the suspected ADR resolve when the suspect drug was stopped? What are the results of any relevant biochemical tests e.g. renal function tests, liver function tests, full blood count, biopsies, relevant ultrasound or screening tests. Does the enquirer want to know which drug, A or B, is more likely to have caused side effect X? Is the enquirer involved in a legal case? Always be aware that this may be the scenario (often enquirers do not mention this). Has the manufacturer been informed or a yellow card completed? Prospective enquiries Does the enquirer think that the patient may be at particular risk of an ADR e.g. a patient with a history of an ADR to the same class of drugs? If so, what were the signs and symptoms of the suspected previous reaction? N.B. caution may be required when using other drugs with similar ADR profiles. Does the enquirer just want general information e.g. for informing a patient of possible side effects? Does the enquirer want to know more information about a specific side effect e.g. because the patient has asked? Does the enquirer want to assess the risk/benefit comparison between two drugs e.g. which is safer, drug A or drug B (often in relation to a specific side-effect)? Some enquiries will involve a mixture of the two e.g. if a patient has a reaction which is subsequently thought to be an ADR then it could be anticipated that the enquirer will want suggestions for alternatives. Resources Source Notes First-line resources In-house past enquiries. Relevant Medicines Q&As via www.nelm.nhs.uk
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Source Notes Electronic Medicines For new drugs, adverse reaction information in the SPC comes from Compendium clinical trials, data are limited and uncommon idiosyncratic reactions are unlikely to be included. The SPCs for more established drugs include www.medicines.org.uk/emc/ adverse reactions identified by postmarketing surveillance studies and spontaneous reporting schemes. BNF www.bnf.org Clinically relevant adverse effects are listed, generally in order of frequency and arranged broadly by body systems. AHFS Drug Information via Monographs often contain extensive information on ADRs. www.medicinescomplete.com Martindale via www.medicinescomplete.com Meyler's Side Effects of Drugs, Presented as individual drug monographs in alphabetical order with Dukes and Aronson. general class monographs complemented by specific drug monographs. Also contains information on non-drugs e.g. toxins, foods. Additional resources (tailor to local use/availability) Adverse Drug Reactions, Lee A. Describes ADRs by organ class, lists commonly implicated drugs and gives tips on management of suspected ADRs. N.B. most recent edition is 2006. Davies's Textbook of Adverse Chapters are arranged by system and adverse effect. NB. Now relatively Drug Reactions, Davies et al. out of date (1998). MHRA Drug Analysis Prints Complete listings of the suspected ADRs reported to the MHRA through (DAP) via MHRA the Yellow Card Scheme by healthcare professionals and patients are provided in Drug Analysis Prints (DAPs). When sending DAP data to an MHRA Drug Analysis Prints enquirer it is important to enclose a sheet explaining how to interpret this (download from the MHRA website). Micromedex Drugdex Drug Evaluations - Reports are normally referenced. www.thomsonhc.com Reactions weekly Paper journal or via Adisonline. www.adisonline.info Bibliographic databases e.g. Suggested terms: the reaction with the subheading ‘chemically induced’ Medline, Embase (Medline) or ‘side effect’ (Embase) and/or the drug name with the subheading ‘adverse effects’ (Medline) or ‘adverse drug reaction’ (Embase). Drug Safety Update via MHRA A regular monthly electronic bulletin providing information and clinical advice website at Drug Safety Update from the MHRA and the Commission on Human Medicines Manufacturers’ Medical Companies are legally obliged to follow up telephone enquiries about Information departments. ADRS (by sending an adverse event reporting form). Natural Medicines Includes adverse effects of herbal medicines. Comprehensive Database www.naturaldatabase.com Local resources
Answering the enquiry For retrospective enquiries use the information you have obtained from the 'background information' questions and try to assess causality using the following criteria: o The nature of the reaction - certain disorders are commonly drug-induced e.g rashes, constipation, gastrointestinal haemorrhage. o Previous SPC or literature reports describing the reaction.
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o The timing of the reaction can vary but most ADRs appear shortly after a drug is started or the dose is increased. o Outcome on drug withdrawal, if resolution occurs this is a positive dechallenge. o Rechallenge outcome, although positive rechallenge strongly suggests drug cause deliberate rechallenge is rarely justifiable and should not be suggested. o Risk factors, some patients have an increased susceptibility to ADRs (e.g. children, elderly, multiple disease states, atopic patients). o Laboratory and diagnostic tests should indicate if there is a non-drug cause, ADRs are often a diagnosis of exclusion. When interpreting ADR data for the enquirer, be clear about the limitations of the Yellow Card data. Warn that although there may be X number of reports we do not know the Y number of people who have received the drug, therefore you cannot extrapolate to predict ADR incidence. If there is a strong suspicion that an ADR has been identified encourage completion of a Yellow Card or offer to complete the report yourself. Keywords: The drug name, disease term for the adverse effect.
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Drugs in breastfeeding Background information Is the mother already breastfeeding? Is the mother already taking the medicine in question? Identify the drug, indication, dose and frequency, route of administration and intended duration of treatment. Has the mother taken the drug during pregnancy? If so, identify whether it is appropriate to switch to an alternative if necessary. Note exposure during pregnancy does not confer safety during breastfeeding. How old is the infant, and is he/she premature or full-term? Is the infant fed exclusively with breast milk? (Exposure is less in infants who are being weaned or who have a mixture of breast milk and formula milk.) Is the infant well? Is there anything to suggest that the infant may be at increased risk of drug harm, e.g. impaired kidney or liver function? Has the infant been prescribed any medicines? Is drug therapy necessary? Has an alternative been considered or tried? Resources Source Notes First-line resources In-house past enquiries. Relevant Medicines Q&As via www.nelm.nhs.uk LactMed This database is part of TOXNET, the US equivalent of Toxbase and is http://toxnet.nlm.nih.gov/cgi- freely available. To search for a drug monograph type the drug or brand bin/sis/htmlgen?LACT name in the box and click on ‘search’; then select the monograph you want from the list of hits. Monographs are referenced. The date of last revision is at the bottom. Medications and Mothers’ Milk. Standard US reference text on the safety of medicines during Hale, T. breastfeeding. The preface includes key points about breastfeeding and medicines, and highlights the benefits of breastfeeding. Individual drug monographs are in alphabetical order and there is an index at the back. Appendices provide information on chemotherapy agents, radiopharmaceuticals, contraceptives and cold/flu remedies. Note that brand names may differ in the UK. Also available electronically (subscription required) Electronic Medicines SPC section 4.6 (pregnancy and lactation) clarifies the licensed status of Compendium medicines use during lactation. NB: Statements in SPCs are sometimes www.medicines.org.uk/emc more cautious than current evidence requires and should not be used as the only source of information. UKMi Drugs in Lactation This website is maintained by the UKMi Drugs in Lactation Advisory www.ukmicentral.nhs.uk Service. It is a useful quick reference source but provides only brief information. There are two ways of using it: Guidance: Provides general advice and information on specific drugs classes (click on the class you want). Quick ref guide: A quick reference table classifies individual medicines and drug classes as red, amber or green for use in breastfeeding. Note. This was last reviewed in November 2008. Due for major update during 2011.
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Source Notes First-line resources In-house past enquiries. Additional resources (tailor to local use/availability) Drugs during Pregnancy and Chapter 3 includes general information about medicines use during Lactation. Schaefer et al. breastfeeding. Chapter 4 provides information for individual agents and drug classes. Use the index to find the page you want. Each monograph has a boxed ‘recommendation’ at the end. Note published in 2007 BNF for Children www.bnfc.org If information is lacking from other sources, BNFC can be consulted to see if the drug can be used in neonates or infants. The dose advised can be compared to the theoretical dose the infant will receive via the breast- milk. Information on drug safety in breastfeeding is included in drug monographs. However, this is too brief to be of real value (note—the same information is held in BNF monographs) UKMi Drugs in Lactation UKMi Trent (0116 258 6491) and West Midlands (telephone 0121 424 Advisory Service. 7298) jointly provide support directly to local MI centres for complex enquiries or advice in high risk situations such as prematurity and low birth weight. Ensure you have adequate background information, and have checked sources available to you before contacting the specialist service. Drugs in Pregnancy and Standard US reference text on the safety of medicines in pregnancy and Lactation. Briggs GG et al. breastfeeding. Each drug monograph has a section on breastfeeding at the end. Individual drug monographs are in alphabetical order. However, note that breastfeeding is not the main focus. Maudsley Prescribing Chapter 7 contains a section on the choice of psychotropic medicines in Guidelines. Taylor D et al. lactation. Psychotropic Drug Directory. Chapter 3 contains a section on the choice of psychotropic medicines in Bazire S. lactation. Prescribing in Pregnancy. Rubin Chapter 14 of this UK reference has information on the safety of drugs in D. breastfeeding. The Breastfeeding Network This organisation is a registered charity providing independent advice and support to breastfeeding women and others. Some of the www.breastfeedingnetwork.org. information is unreliable and is not recommended for use by health uk/ professionals. However, as patients may be using these leaflets, it can be helpful to know what they advise. The website has a section on drugs in breastmilk (click on the link, the tabs towards the top of the screen). There are two types of document available: Drug information factsheets. These have the date produced on the bottom but are not always referenced. Medication FAQs (pdf document) Bibliographic databases e.g. Suggested terms: BREAST FEEDING, BREAST MILK, LACTATION, Medline, Embase, Medicines. MILK-HUMAN (NB: Nursing is a US term for breastfeeding). For recommended search strategies see: www.ukmi.nhs.uk/activities/specialistServices/default.asp?pageRef=2 Local resources
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Answering the enquiry The following principles should be followed when prescribing for breastfeeding mothers: The benefits of breastfeeding must be recognized; a recommendation to stop breastfeeding must not be made lightly. The benefit and risk to both mother and infant must be considered. It is seldom required that a breastfeeding mother stop breastfeeding in order to take a medication. Neonates and premature infants are at greater risk from exposure to drugs via breast milk, because of immature excretory functions and the consequent risk of drug accumulation. Infants exposed to drugs via breast milk should be monitored for unusual signs or symptoms. Avoid unnecessary drug use and limit use of over-the-counter (OTC) products. Avoid use of drugs known to cause serious toxicity in adults or children. Drugs licensed for use in infants do not generally pose a hazard to full-term, healthy infants. Choose a regimen and route of administration which presents the minimum amount of drug to the infant e.g. breastfeed immediately pre-dose to avoid exposure to peak levels. It is best to avoid long-acting preparations, especially those of drugs likely to cause serious side effects (e.g. antipsychotic agents), as it is difficult to time feeds to avoid significant amounts of drug in breast milk. Multiple drug regimens may pose an increased risk especially when adverse effects such as drowsiness are additive. Avoid new drugs if a therapeutically equivalent alternative with more safety data is available.
Keywords BREAST FEEDING, LACTATION, MILK-HUMAN, drug name, and disease name (if appropriate).
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Compatibility of intravenous drugs Background information How many intravenous lines are available, what type of lines are they (central or peripheral), how many lumens does each line have? Can other lines be inserted if necessary? What is the patient receiving through the lines at the moment? Ask about blood products, TPN, etc. as well as drugs. For current drugs: o Check dose and administration schedule - are they being given continuously, or by short infusion or as a bolus? If continuous infusion, can they be given intermittently? o What diluents and concentrations are being used? o Are filters being used? If yes, where are they placed and what size are they, e.g. 0.2 micron? o Can any drugs be discontinued? Which drugs are to be added and why? Which brand(s) will you be using? How will the drugs be mixed, e.g. in the same bag, the same intravenous line (Y site), same syringe or the same venflon? Is there a choice of drugs that could be used? Are there any limitations on choice, e.g. fluid and electrolyte restrictions, renal or hepatic dysfunction? Can the patient tolerate administration by another route, e.g. nasogastric tube, oral, rectal, intramuscular, subcutaneous, topical? N.B. If the enquiry concerns the compatibility of drugs in a syringe driver for subcutaneous administration please refer to the ‘Compatibility of subcutaneous drugs’ monograph.
Resources Source Notes First-line resources In-house past enquiries. Relevant Medicines Q&As via www.nelm.nhs.uk BNF www.bnf.org Contains information about compatible/incompatible diluents. BNF for Children www.bnfc.org Electronic Medicines SPCs may contain information about compatibility of commonly used Compendium admixtures. www.medicines.org.uk/emc Handbook on Injectable Drugs. N.B. This is a US resource, but it does include UK drug monographs Lawrence A Trissel. (see section at the back in the paper version). www.medicinescomplete.com UCL Hospitals Injectable Drug Paper version also available. Administration Guide www.uclhguide.com Additional resources (tailor to local use/availability) Pharmaceutical manufacturer. They may have unpublished data, although many generics manufacturers have little or no information. Micromedex Contains information about compatibility of intravenous admixtures if www.thomsonhc.com known. The Injectable Medicines Guide *Only free to contributing Trusts, all Trusts in Wales & N.Ireland. Paper www.injguide.nhs.uk version also available.
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Source Notes First-line resources In-house past enquiries. AHFS Drug Information via Information in the stability section of individual monographs. www.medicinescomplete.com National Extravasation Has information on recognising and treating extravasation and a Information Service database of drugs, their pH and known reactions following extravasation. www.extravasation.org.uk Website is not currently updated but still a useful resource. Bibliographic databases e.g. Suggested terms: ADMINISTRATION-INTRAVENOUS and DRUG Medline, Embase, Pharmline INCOMPATIBILITIES (via the medicines management section of NeLM) Local resources
Answering the enquiry When checking compatibilities, consider alternative ways of solving the problem, e.g. by using other routes of drug administration. You must consider problems associated with other routes and whether they would be appropriate for that particular patient. When answering this type of enquiry consider: Are all drugs essential? What are the possible mechanisms of interactions – chemistry i.e. pH, adsorption? Is it possible to administer drugs by an alternative route? Could another line be inserted? Is there more than one option available, i.e. could a different drug be used to avoid a compatibility problem? Could the timing of administration be altered to avoid the need for mixing?
Keywords: drug names, ADMINISTRATION-INTRAVENOUS, DRUG INCOMPATIBILITIES
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Compatibility of subcutaneous drugs Background information Which other medicines is the patient receiving, what are they for and by what routes are they being given? Which drugs need to be mixed, what are they for and what is the dose? What is the diluent to be used and the concentration required or the preferred total volume? Over what time period is the infusion to be given? What other routes of administration are available, e.g. intravenous lines? Establish how the patient is fed – an enteral feed tube offers a potential alternative administration route. N.B. If the enquiry concerns the compatibility of drugs for intravenous administration please refer to the ‘Compatibility of intravenous drugs’ monograph. See also ‘Palliative Care’ monograph.
Resources Source Notes First-line resources In-house past enquiries. Relevant Medicines Q&As via www.nelm.nhs.uk BNF www.bnf.org Section on prescribing in palliative care includes information about drug administration via syringe drivers. The Syringe Driver. Contains comprehensive information about two or more admixtures of Dickman, Schneider and Varga. commonly used combinations. Palliative Care Formulary Once registered, click on the menu button ‘SDSD’ to check the (PCF3). Twycross et al. compatibility of up to six drugs in the Syringe Driver Survey Database www.palliativedrugs.com by selecting drug names from drop down menus. Alternatively click on the menu button ‘Formulary’, then scroll down to Appendix Four (A4): Compatibility charts. The charts summarise compatibility data for commonly used 2-drug and 3-drug combinations. General information on continuous subcutaneous infusions is in section 18. Paper version also available. Handbook on Injectable Drugs. N.B. This is a US resource, but it does include UK drug monographs Trissel LA. (see section at the back in the paper version). www.medicinescomplete.com Additional resources (tailor to local use/availability) Electronic Medicines However, very few injectable drugs are licensed for subcutaneous Compendium injection or infusion. www.medicines.org.uk/emc Palliative Medicine Handbook. Textbook available free online. Click on ‘SD drug compatibility’ in the Ian Back. Index to search for data on compatibility of specific drug combinations. www.book.pallcare.info Paper version also available. Palliative Care Matters website Associated with the Palliative Medicine Handbook. Click on ‘syringe www.pallcare.info drivers’ in the Main Menu to enter drug compatibility database and search for data on compatibility of specific drug combinations.
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Source Notes First-line resources In-house past enquiries. Symptom Relief in Palliative Freely available via NHS Evidence. Click on the menu button ‘NHS Care. Dean, Harris, Regnard Athens Resources’ then ‘E-books’. Log in with your Athens password. and Hockley. Type ‘symptom relief’ in the search box. Click on ‘Read Book’. The chapter on ‘Problems with syringe pump infusions’ (within Drug Information) contains useful trouble shooting advice. Paper version also available. Oxford Handbook of Palliative Freely available via NHS Evidence. Click on the menu button ‘NHS Care. Watson M et al. Athens Resources’ then ‘E-books’. Log in with your Athens password. Type ‘oxford palliative’ in the search box. Click on ‘Read Book’. Chapter 4 contains general information on the principles of drug use in palliative care, including syringe drivers. Paper version also available. Oxford Textbook of Palliative Freely available via NHS Evidence. Click on the menu button ‘NHS Medicine. Hanks G et al. Athens Resources’ then ‘E-books’. Log in with your Athens password. Type ‘oxford palliative’ in the search box. Click on ‘Read Book’. Useful general information in Chapters 8 and 10. Paper version also available. Bibliographic databases e.g. Suggested terms: SUBCUTANEOUS-DRUG-ADMINISTRATION, Medline, Embase, Pharmline INJECTIONS-SUBCUTANEOUS, ADMINISTRATION- (via the medicines management SUBCUTANEOUS section of NeLM) Local resources
Answering the enquiry There is a Macmillan nurse attached to every GP practice. For enquiries about managing a specific patient in primary care (other than straightforward medicines information queries), advise the enquirer to contact this nurse. Some drugs are too irritant to be given subcutaneously, e.g. prochlorperazine, diazepam and chlorpromazine. Some drugs should never be mixed e.g. phenobarbital. Many palliative care units will always give dexamethasone in a separate syringe driver. Mixing two or more licensed drugs for administration via a syringe driver, where one is not a vehicle for administering the other, falls within the definition of manufacture and results in a new, unlicensed product. The MHRA and Commission on Human Medicines (CHM) have explored options for changing medicines legislation. Following a public consultation, a CHM working group produced formal recommendations for changes to the Misuse of Drugs Regulations. In the meantime the MHRA would not consider taking enforcement action for breaches of medicines legislation by a Nurse or Pharmacist Independent Prescriber engaging in the long standing accepted practice of prescribing and administering (and providing directions to others to administer) a mixture of licensed drugs via a single injection or a syringe driver unless it would be in the public interest to do so. The CHM working group recommends that mixing should be avoided where possible, only done when clinically appropriate and essential to meet the patient’s needs, and instructions to mix must be in writing. Use of more than one syringe driver may be an option if there are compatibility problems and alternative routes are unsuitable. Use of a larger total volume will improve the stability of many drug combinations and may be an option for some patients.
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Keywords: Drug names, ADMINISTRATION-SUBCUTANEOUS, DRUG INCOMPATIBILITIES
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Complementary medicine Background information Is the patient already taking the alternative or complementary medicine or do they want to start taking it? Identify the alternative medicine, indication, route, strength, dose and frequency, formulation, manufacturer and source if possible. If applicable, how long has it been taken for? Are they taking the product as a short course, cyclically or long-term? Has the patient self-diagnosed the condition that they are seeking to treat? If they have, perhaps they should consider speaking to a healthcare professional first. Does the patient take any conventional medication? Is there any history of ADRs or allergies? Check current and past medical history. Are they pregnant or breast feeding? Where did the patient hear about this or who recommended starting it?
Resources Source Notes First-line resources In-house past enquiries. Relevant Medicines Q&As via www.nelm.nhs.uk Natural Medicines This is the preferred source. Comprehensive Database www.naturaldatabase.com Herbal Medicines via Target audience is pharmacists. www.medicinescomplete.com Additional resources (tailor to local use/availability) Meyler's Side Effects of Drugs. General class monograph on herbal medicines complemented by Aronson JK. specific drug monographs. Homeopathic Pharmacy. Kayne S. Dietary Supplements. Mason P. via www.medicinescomplete.com The Desktop Guide to Complementary and Alternative Medicine. Ernst E. Martindale via See chapter on Miscellaneous Drugs and Other Substances and www.medicinescomplete.com individual monographs. Drugs During Pregnancy and See chapter 2.19 – Herbs during pregnancy. Lactation. Schaefer et al. Stockley’s Drug Interactions via Index term – herbal medicines but also see individual drugs. www.medicinescomplete.com Stockley's Herbal Medicines Interactions via www.medicinescomplete.com
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Source Notes First-line resources In-house past enquiries. Safety of Herbal Medicines Latest safety advice from the MHRA. Go to A-Z index>H>Herbal safety Herbal safety advice : MHRA advice. By April 2011 all manufactured herbal medicines will be required to have either a traditional herbal registration (THR) or a Marketing Authorisation (MA). Products will therefore be required to meet specific standards of safety and quality. However this only applies where products come within the definition of a medicinal product. Many herbal products will continue to be available as food supplements. The MHRA are currently preparing information sheets on herbs that have been assessed for THR product registration which can be accessed via: http://www.mhra.gov.uk/Howweregulate/Medicines/Herbalmedicines/Her balsafetyadvice/Herbalinformationsheets/index.htm The National Centre for Access to clinical trials, fact sheets, safety alerts. Complementary and Alternative Medicine http://nccam.nih.gov Focus on Alternative and A journal that reviews and critically comments on new research in Complementary Therapies complementary medicine published worldwide. (FACT) http://journals.medicinescomplet e.com/journals/fact/current Idis Herbalinks A website that provides critical appraisal of herbal websites. www.uiowa.edu/~idis/herbalinks Quackwatch Useful for checking out dubious complementary medicine claims. An www.quackwatch.org associated site Homeowatch looks at homeopathic medicines. www.homeowatch.org Cochrane database via Contains numerous systematic reviews of complementary therapies. www3.interscience.wiley.com Chinese Medicines Advisory Chinese Medicines Advisory Service (ChiMAS) run by Guys and St Service Thomas’ NHS hospital trust. ChiMAS provides advice on the safe use of http://www.chimas.org/Enquiries Chinese and other traditional medicines, responding to all levels of .aspx enquiry from health professionals. Health professionals, including pharmacists, can contact ChiMAS for information on safety, potential interactions, adverse health effects or general background on the use of Chinese or Traditional medicine. ChiMAS can be contacted by fax, email or telephone. Traditional Chinese Medicine Useful for finding the Latin name for the various ingredients, which can Basics then be used to search the standard alternative medicine databases. tcmbasics.com/materiamedica.h tm Bibliographic databases e.g. Suggested terms: drug name, HERBAL MEDICINE, HERBALISM, Medline, Embase. MEDICINE-HERBAL, DRUGS-CHINESE-HERBAL, HERBAL- PREPARATIONS, DIETARY SUPPLEMENTS, DIET- SUPPLEMENTATION Manufacturers. Individual manufacturers may be able to provide information. Several have websites www.pottersherbals.co.uk, www.nelsonshomoeopathy.co.uk, www.hollandandbarrett.com. Local resources
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Answering the enquiry Ensure that the enquirer is aware of the lack of quality, reliable information in the literature regarding complementary medicines. There is also an abundance of misleading information which is usually what patients have access to! This is particularly true of internet based resources. When assessing the quality of a website it is useful to ask yourself the following questions: o Is the information up-to-date? o Who has written the information? o Who ‘owns’ the website? Could there be a conflict of interest? o Are claims supported by reliable evidence? o Is any information provided about risks associated with treatments?
Overall there is limited information available regarding interactions between complementary/alternative medicines and conventional medicines. Occasionally herbal products may be contaminated with other active substances. As with conventional drug interactions, herb-drug interactions may be pharmacodynamic or pharmacokinetic. It is often difficult to assess whether a complementary medicine will interact with a conventional medicine. In this situation it may be prudent to advise against using them together. In most cases this is not because there is evidence of an interaction but because there is a lack of evidence to assess risk. Individuals using a complementary medicine should be advised to be consistent with the brand, dose and frequency of administration of the product being used. Enquirers often ask about the likelihood of an interaction between prescribed and complementary medicines. Some herbal products may compromise the efficacy of conventional medicines and there are particular concerns for those individuals receiving drugs with a narrow therapeutic window such as warfarin, phenytoin and digoxin. Ideally where there is limited safety data for a particular herbal preparation it would be prudent to avoid their use in patients receiving these types of medicines or in those whose therapy is deemed critical e.g. chemotherapy. Pregnancy – there is very limited information on the use of alternative or complementary medicines in pregnancy and should only be recommended after careful consideration of the risks and benefits. Some preparations will be contraindicated in pregnancy – always consult a specialist source.
Keywords: Preparation name if possible, if not form of alternative medicine e.g. HERBAL MEDICINE, DIETARY SUPPLEMENTS, AROMATHERAPY, HOMEOPATHIC MEDICINES, MEDICINE-CHINESE TRADITIONAL. .
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Contraception (hormonal) Background information Hormonal contraception Type and name of hormonal contraceptive: combined oral contraceptive (COC), progesterone only pill (POP), patch, depot injection, implant, intrauterine system (IUS), vaginal ring. Contraceptive pill: Name, type of pill (POP / COC; standard strength / low strength oestrogen; 21 or 28 day)? 21 or 28 day pill? Patch, injection, implant: Name of preparation? Already taking or planned to take? Other medical conditions? Other medicines, including complementary and OTC? Are they breast feeding? Smoking status (relevant if the choice of agent is being discussed)? Age of patient (relevant if choice of agent is being discussed)?
Missed contraceptive pills Name of pill, type of pill (POP/COC/standard strength/low strength oestrogen) and number of days in the pack (21 or 28 days)? N.B. Qlaira is a new COC with different missed dose advice – refer to the Summary of Product Characteristics. What time does she usually take her pill? How many pills have been missed? Where in the cycle were they missed How many pills are left in the pack? COC: were the previous 7 pills taken correctly? POP: were the previous 2 pills taken correctly? COC only: sexual intercourse, without any form of contraception, during the preceding 7 days? Other medical conditions? Other medicines, including complementary and OTC?
Delayed or detached patch Patch: Name of patch (Evra)? When does she usually change the patch (day and time)? Which patch has been delayed or detached? Delay in applying a new patch: how long? Detached patch: how long? Sexual intercourse, without any form of contraception, during the preceding 7 days? Other medical conditions? Other medicines, including complementary and OTC?
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Delayed injection or implant rods Name of injection (Depo-Provera, Noristerat) or implant (Implanon - now replaced by Nexplanon). How long is the delay in administration? Sexual intercourse since replacement was due? Other medical conditions? Other medicines, including complementary and OTC?
Dislodged or delayed inter-uterine progesterone only system (Mirena coil) When did the coil dislodge? How long is the delay in administration? Sexual intercourse during the preceding 7 days?
Vaginal ring (Nuvaring) Delay in inserting new ring: how long? Delay in removing the ring: how long? Ring accidentally expelled: for how long and in which week? Has the ring broken? Sexual intercourse, without any form of contraception, during the preceding 7 days?
Emergency contraception What is the reason for needing it e.g. if missed pill may need to give advice on when to restart the pill again and additional precautions required. How long is it since unprotected intercourse occurred? Other medical conditions and medicines, including complementary and OTC? Age of patient? Is the woman likely to be pregnant or are they breast feeding? Has any other from of emergency contraceptive been used in the current cycle? For enquiries regarding drug interactions, adverse effects, pregnancy or breast feeding associated with contraception, refer to the relevant monographs.
Resources Source Notes First-line resources In-house past enquiries. Relevant Medicines Q&As via Advice may differ compared to some other sources www.nelm.nhs.uk BNF www.bnf.org Advice may differ compared to some other sources. Missed pill advice is different to that advocated by the World Health Organisation, Faculty of Sexual and Reproductive Healthcare and FPA. Electronic Medicines Advice may differ compared to some other sources. Missed pill advice is Compendium different to that advocated by the World Health Organisation, Faculty of www.medicines.org.uk/emc Sexual and Reproductive Healthcare and FPA.
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Source Notes First-line resources In-house past enquiries. Contraception: Your Questions Comprehensive resource covering all forms of contraceptives including Answered. Guillebaud J. injectables, implants, IUDs and EHC. Advice for missed combined oral contraceptives is different to that advocated by the World Health Organisation, Faculty of Sexual and Reproductive Healthcare and FPA. The Pill. Guillebaud J. Written for the public. Family Planning Association. Website aimed at the general public, good for contact details of local www.fpa.org.uk clinics and good basic information about contraception. Helpline (England): Click Help & Advice> contraception 0845 1228690 Information department is staffed by nurse advisors Mon-Fri 9:00-18:00. IPPF (International Planned Can be used to identify foreign contraceptive pills. Registration is Parenthood Federation) required. Directory of Hormonal Contraceptives http://contraceptive.ippf.org/ Additional resources (tailor to local use/availability) Faculty of Sexual and The website of the Royal College of Obstetricians and Gynaecologists. Reproductive Healthcare Click Publications www.ffprhc.org.uk Guidelines including choice of a contraceptive agent at different ages, in breast feeding, inflammatory bowel disease, interactions, missed pills and using pills outside their product licence, EHC, new product reviews. NB. Advice may differ from that in SPCs and the BNF. Clinical Knowledge Summaries: Covers risk and benefits of methods available, including failure rates and Contraceptive guidance factors that influence choice. http://cks.library.nhs.uk/contrace ption World Health Organization Click Publications>Family Planning> www.who.int/reproductivehealth/
NICE guidance: Long acting Includes information on effective and appropriate use of LARC and reversible contraception provides advice and information. www.nice.org.uk Netdoctor www.netdoctor.co.uk Useful resource for members of the public and states that advice in SPCs on missed pills is out of date. Bibliographic databases e.g. Suggested terms: CONTRACEPTION, CONTRACEPTION- Medline, Embase. POSTCOITAL, EMERGENCY CONTRACEPTION, CONTRACEPTION- BARRIER, plus drug name. Local resources
Answering the enquiry When answering an enquiry regarding missed pills make your answer as clear and practical as possible, i.e. if they are to use additional contraceptive measures state for how long, what they do when they finish the packet of pills, when they restart their pill after EHC etc. Choice of therapy, ensure patient preference and concomitant risk factors have been considered.
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Keywords: CONTRACEPTIVES-ORAL or CONTRACEPTIVES POSTCOITAL or use CONTRACEPTION if neither of these terms are applicable. Also use individual estrogen or progestogen if appropriate.
Cytotoxic medicines
Background information Most hospitals will have a specialist oncology pharmacist and will have chemotherapy protocols to follow. These experts will be better placed to answer enquiries about cytotoxic medicines and regimes for the treatment of patients with cancer. For any enquiries about treatment regimes, refer to local policy. For enquiries about manufacturing of cytotoxic medicines, the aseptic manufacturing unit in the hospital should be contacted.
Resources Source Notes First-line resources In-house past enquiries. Relevant Medicines Q&As via www.nelm.nhs.uk BNF www.bnf.org Chapter 8 contains general information about cytotoxic drugs. Electronic Medicines The Summary of Product Characteristics contains information about the Compendium administration of cytotoxic medicines and lists warnings, precautions and www.medicines.org.uk/emc adverse effects. Cytotoxics Handbook. Most manufacturing units hold this resource. Essential for MI centres answering Allwood, M et al. a significant number of cytotoxic-related enquiries. Additional resources (tailor to local use/availability) Specialist Centre for Can assist with specialist advice on drug use in cancer patients. Phone them Oncology is The Royal only after a thorough search. Make sure you have all the relevant background Marsden NHS Foundation information. Trust. Tel: 0208 661 3456 (medicines information). Local cancer network. Use Google to search for contact details of the cancer network in your area. NICE guidance - Cancer http://guidance.nice.org.uk/ Topic/Cancer Local resources
Answering the enquiry Unless you are familiar with the chemotherapy regimes used for the treatment of cancer it would be safer not to attempt to answer the enquiry. Liaise with the specialist oncology team and oncology pharmacist.
Keywords: CYTOTOXINS, drug name.
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Dental Background information For antibiotic prophylaxis (including endocarditis) enquiries: The reason for considering prophylaxis e.g. joint prosthesis, immunosuppressed, endocarditis What is the dental procedure to be undertaken? Any allergies to antibiotics and details of the reaction? Has the patient recently had any antibiotics? If so, which, what was the dose, duration and indication? For antibiotic treatment choice enquiries: What is the indication for the antibiotic? Any allergies and details of the reaction? Has the patient recently had any antibiotics? If so, which, what was the dose, duration and indication? Dental prescribing enquiries: Is the dentist treating an NHS or private patient? What is the indication for the prescription?
Resources Source Notes First-line resources In-house past enquiries. Relevant Medicines Q&As via www.nelm.nhs.uk BNF www.bnf.org At the front a section on dental prescribing includes: Medical emergencies in dental practice Medical problems in dental practice Advice on prescribing for oral bacterial infections, or for prophylaxis can be found at the beginning of section 5. Within the monographs of the drugs that dentists can prescribe is the statement ‘Dental prescribing on NHS’ followed by the list of preparations. Secretaries of State list (‘Dental Practitioners’ Formulary’) of products prescribable by a dentist on an NHS prescription can be found between Appendix 9 and the Index of manufacturers. Electronic Medicines Compendium www.medicines.org.uk/emc Additional resources (tailor to local use/availability) UKMi specialist centre - North See Specialist services>Drugs in Dentistry page for details of West Medicines Information background information required before contacting the centre. Centre 0151 794 8206 Adult Antimicrobial Prescribing Useful for antibiotic, antifungal and antiviral prescribing. in Primary Dental Care for General Dental Practitioners (2000, Faculty of General Dental Practitioners (UK). Churchill's Pocketbook of Good for understanding dental procedures and terminology. Clinical Dentistry.
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Source Notes First-line resources In-house past enquiries. Oxford Handbook of Clinical Good for understanding dental procedures and terminology. Dentistry. Medical Problems in Dentistry, Useful for dental management issues, relevant to a large number of Scully and Cawson. medical conditions. Pharmacology and Dental Therapeutics, Seymour et al. Oral Microbiology, Marsh and Martin. Local Anaesthesia in Dentistry, Good for local and systemic adverse effects of local anaesthetics. Robinson et al. Drug Dictionary for Dentistry, Useful for oral adverse effects and interactions. Meechan and Seymour ADA Guide to Dental American text. Therapeutics. Guidance for the management of natural rubber latex allergy in dental patients and dental healthcare workers (Faculty of General Dental Practitioners UK). British Dental Association Useful 'Fact Files' e.g. filling materials safety, latex allergy, dental care http:/// www.bda.org during pregnancy, bisphosphonates and 'Advice Sheets' e.g. Prescribing in general practice. Access to documents on the website is restricted to registered dental health professionals. For access to relevant documents contact the Information Centre on 020 7563 4545 or email: [email protected] General Dental Council The statutory body which regulates the dental profession in the UK. www.gdc-uk.org. Online access to the dental register. Septodont www.septodont.co.uk One of the biggest manufacturers of dental materials. The website contains SPCs and safety data sheets. Registration (free) required Dentsply www.dentsply.co.uk Has the SPCs for all Dentsply local anaesthetics. Bibliographic databases e.g. Suggested terms: see range of keywords below. Medline, Embase Local resources
Answering the enquiry Dentists see patients who may be taking a lot of medicines due to medical conditions and usually have no other resource than the BNF. All dental procedures undertaken in primary care can be classed as minor surgical procedures (even if the dentist thinks they are major for them!). This has implications when considering choice of prophylaxis, analgesia, management of patient on corticosteroids etc. Use the analogy: insertion of joint prosthesis (major) vs two or more tooth extractions (minor). Keywords: Use the drug name where appropriate. Other useful keywords include; DENTISTRY-OPERATIVE = dental procedures e.g. extractions (TOOTH EXTRACTION) ROOT CANAL THERAPY, DENTAL MATERIALS = impression materials, filling materials, cements, toothpastes, DENTAL CARIES, DENTIFRICES = toothpastes, CARTRIDGES-DENTAL, DENTAL ALLOYS = mercury amalgam fillings, TOOTH DISEASES, TOOTH EXTRACTION, PERIODONTAL DISEASES including GINGIVITIS,
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PERIODONTITIS, MOUTH DISEASES including TOOTH DISEASES, TASTE DISORDERS, GLOSSITIS, XEROSTOMIA = dry mouth, ANAESTHESIA-DENTAL, ANAESTHESIA-LOCAL, ANAESTHETICS-LOCAL, and PROPHYLAXIS, for endocarditis enquiries. Drug use in hepatic impairment Background information Establish patient details, including age, sex etc. What is the diagnosis and previous medical history if relevant? Type of liver disease and cause (e.g. acute, chronic, cirrhosis etc). Results of any immunological/virological screens (eg. hepatitis) and other diagnostic tests (eg. biopsies). Symptoms (e.g. ascites, jaundice, varices, encephalopathy), extent and severity. Liver function tests (bilirubin, alkaline phosphatase, ALT, AST, GGT) - most recent ones if possible. Are they stable or changing? What are the most recent albumin levels? What is the most recent INR/prothrombin time for clotting? What is the current medication including doses and any changes/short courses in last 2-3 months (e.g. antibiotics)? Ask about renal function. Multi-organ failure often co-exists but enquirers often forget to mention this. Is it suspected that the hepatic impairment is drug induced? Include questions about duration and dose of suspected drug, timescales, type of liver injury, how patient has been managed, what other drugs are being taken or were taken recently, and could there be another cause? If the hepatic impairment is suspected to be drug related refer to the monograph ‘Adverse drug reactions'. If requesting advice on dosage or suitability of a drug in hepatic dysfunction, what is the indication for the drug and have alternatives been considered? What agent would normally be used if the patient did not have liver dysfunction?
Resources Source Notes First-line resources In-house past enquiries. Relevant Medicines Q&As via www.nelm.nhs.uk BNF www.bnf.org Use this as an initial source but remember minimal information is included and it is inadequate as a sole reference source. NB. The absence of information does not imply safety. Electronic Medicines SPCs may give advice on the need to reduce doses in hepatic Compendium impairment. The ‘pharmacokinetics’ and ‘undesirable effects’ sections www.medicines.org.uk/emc may also be useful. Martindale via www.medicinescomplete.com AHFS Drug Information via www.medicinescomplete.com Meyler’s Side Effects of Drugs. For information on drug induced hepatic injury. Dukes and Aronson.
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Source Notes First-line resources In-house past enquiries. Drugs and the Liver. A guide to Covers background information on liver function, the principles of drug drug handling in liver use in liver disease and includes a section of worked examples of dysfunction. North-Lewis P. commonly asked questions. Includes an ‘aide memoire’ section for collecting background data. Additional resources (tailor to local use/availability) Micromedex Monographs have a 'dosage in hepatic insufficiency' section with links to www.thomsonhc.com more general drug consults e.g. Antidepressant use in chronic liver failure. Also useful for pharmacokinetic and adverse effect data. Pharmacology textbooks. Generally have a brief description of causes and background to liver disease. Therapeutic Drugs. Dollery Useful for pharmacokinetic data if need to work from first principles. Goodman & Gilman’s Has information about drug metabolism and hepatic effects. Pharmacological Basis of Therapeutics. Applied Therapeutics: The There is a section listing drugs reported to cause clinically significant Clinical Use of Drugs. Koda hepatotoxicity and the likely mechanism. Kimble. Handbook of Clinical Drug Data. Includes a table on drug-induced hepatotoxicity. Knoben & Anderson. Pharmaceutical manufacturers May have information about any reduction of doses which may be necessary in hepatic impairment. May have relevant pharmacokinetic details if working from 1st principles. Bibliographic databases e.g. Suggested terms: LIVER DISEASES, BILIARY TRACT DISEASES, Medline, Embase. LIVER-TOXICITY, HEPATITIS-TOXIC, CHOLESTASIS, HEPATITIS, LIVER FUNCTION-IMPAIRED, (NB: take care if using “LIVER DISEASES” - may not include some cholestatic conditions) Local resources
Answering the enquiry The following factors should be considered when deciding an optimum drug treatment for a patient with liver disease: o Type, extent and severity of liver disease o Pharmacokinetics and pharmacodynamics of the drug o Adverse reactions of the drug o Patient specific factors e.g. age, comorbidities, severity of the condition being treated, concomitant medications In patients with hepatic dysfunction, avoid hepatotoxic drugs where possible. Patients with existing hepatic disease are not more prone to hepatotoxicity (unless it is dose-related), but they have diminished reserve hepatic function and may suffer disproportionately if hepatotoxicity does occur. Drug hepatotoxicity on top of existing liver disease will also confuse the diagnostic picture. Even clinically insignificant and/or transient changes in LFTs may confuse the diagnostic picture. For drugs metabolised by the liver, be alert to signs of drug side effects, know what they are and monitor for them. Monitor drug levels where appropriate. Non-systemic treatments should be chosen where possible. Renally excreted drugs are also preferred as long as renal function is normal. Monitor for any changes in renal function.
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Drugs that increase the risk of bleeding should be avoided or used with extreme caution, depending on the severity of liver disease. Drugs that are highly dependent on the liver for deactivation or clearance are likely to need dose reduction in moderate to severe liver disease. Avoid sedating drugs in patients at risk of developing encephalopathy. Many of these drugs have long half-lives and are metabolised by the liver so their duration and intensity of action may be prolonged. The brain also becomes more sensitive to sedating effects in liver disease. A sedative drug may precipitate or mask encephalopathy. The doses of highly protein-bound drugs may need reducing in patients with low albumin levels due to chronic liver disease. Drug prescribing should be kept to a minimum – use the smallest effective doses at the greatest interval, and titrate according to clinical response. Keywords: Include drug names and LIVER FUNCTION-IMPAIRED or LIVER DISEASES
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Pharmaceutical identification
1. Tablet or capsule identification Background information Describe the form, markings, colour, shape, size and weight. What is the likely therapeutic indication? What is the likely country of origin? Is the preparation thought to be prescription/ herbal / illicit? Resources Source Notes First-line resources Tic Tac. Free for Regional Medicines Information Centres. Some A&E units also have access to this. If a particular logo is difficult to describe suggest the enquirer faxes a drawing. For products with few distinguishing features, an accurate weight and measurement of dimensions might help. Additional resources (tailor to local use/availability) Electronic Medicines SPCs describe products in the ‘Pharmaceutical form’ section and you Compendium can search the whole database by clicking on ‘search by section’, www.medicines.org.uk/emc selecting relevant section and entering letters, numbers etc. This will not help with generic products unless they are branded generics. Pharmaceutical manufacturer. If logo or marking suggests a particular company. Local resources
Answering the enquiry If there is a range of hits, highlight the fact that the only definitive way of identifying the preparation is to analyse it. Many of these enquiries involve a third party which may raise ethical questions. Refer to guidance on answering third-party enquiries: http://www.ukmi.nhs.uk/filestore/misc/L&E_ThirdParty2002.pdf From the age of 14, girls may be prescribed oral contraceptives without parental knowledge. If an enquirer is concerned that their child is taking illicit drugs, you can refer them to www.talktofrank.co.uk or 0800 776600. There is a parent section on the website which gives advice on how to broach the subject with their children, as well as information about drugs. General guidance on ‘street’ drugs: o Tablets may be embossed. o Any emboss is typically a picture or symbol, rather than words or numbers. o Often the tablet is crude with a texture like “extra strong mints”. o Tablets are unlikely to be smooth and pure white. o They are never in strip packs. o Street drugs are never coated.
2. Foreign drug identification Background information What is the trade / generic / chemical name including spelling?
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What is the reference source of the drug name e.g. from packaging, dispensing label or from memory? Is the country of origin known? Is the manufacturer known? Describe the form, markings, colour, shape, size and weight. What is the dose, strength and likely indication? Resources Source Notes First-line resources Martindale via www.medicinescomplete.com Internet search. www.google.co.uk Additional resources (tailor to local use/availability) Tic Tac. Free to Regional Medicines Information Centres. Can select option to search American products only: Select ‘product’ tab then ‘American drugs’. Micromedex On ‘Drugs’ tab there is a drug identification option. www.thomsonhc.com Royal Pharmaceutical Society RPS Support has collated a list of websites to help identify foreign database via: medicines from a number of countries. They also hold a collection of www.rpharms.com/best- foreign medicine literature that complements the catalogue of websites practice/identification-of-foreign- listed below medicines.asp Can also be contacted by phone on 0845 257 2570. MIMS via www.mims.co.uk Click on ‘MIMS’ then type name in the ‘MIMS search’ box. Lists all of the products featured in the MIMS reference book and gives detailed descriptions of each product including tablet appearance. AHFS Drug Information via For US products. www.medicinescomplete.com Bibliographic databases e.g. Suggested terms: known spelling of drug name or use truncation/wild Medline, Embase, Pharmline cards if partial name known. (via the medicines management section of NeLM) Local resources
Answering the enquiry Bear in mind that the drug/brand name may be spelt incorrectly. If you cannot identify the product from the available information, advise enquirer to check details or contact original prescriber.
3. Investigational drugs Refer to ‘New Products’ monograph.
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Immunisation Background information Establish the situation the question relates to. Is it a general question about the UK immunisation schedule or is the question regarding the management of a specific patient? Does the question relate to routine childhood immunisation, vaccination for high-risk groups or travel vaccination? For travel medicine, see the Travel Medicine enquiry answering guideline. For questions relating to a specific patient establish age, vaccination history including dates, medical and medication history and allergy status (including food allergies). If an allergy is reported, did this involve anaphylaxis? Has the patient suffered adverse reactions to vaccinations in the past? Is the patient pregnant or breastfeeding (see also the Drugs in Pregnancy and Drugs in Lactation enquiry answering guidelines)? To answer questions about the safety of vaccines given in error, establish exactly what vaccine(s) has been given, including brand name if possible, and when.
For travel related immunisation enquiries see the ‘Travel Medicine’ monograph Resources Source Notes First-line resources In-house past enquiries. Relevant Medicines Q&As via www.nelm.nhs.uk British National Formulary Chapter 14 provides information on vaccines and immunisation. Note www.bnf.org that the vaccine schedules in the BNF may be out of date. BNF for Children www.bnfc.org Chapter 14 provides information on vaccines and immunisation. Note that the vaccine schedules in BNFC may be out of date. Immunisation section of the DH To access click on ‘A-Z’ at the top of the screen then select ‘I’ then website www.dh.gov.uk ‘Immunisation. Latest news is listed in the centre of the screen with links to relevant documents such as Chief Medical Officer (CMO) letters and copies of Vaccine Update, a monthly publication for staff involved in vaccination. Links to the following useful resources are listed on the left hand side of the screen: “Green Book” Comprehensive resource published by the Department of Health, providing information about diseases and vaccines, including advice on Immunisation against Infectious cautions and contraindications. Disease –otherwise known as The Green book. (Click on NB: Ensure you then choose to view the ‘book’ with individual updated ‘Green Book’.) chapters and then choose to download (view) an updated chapter. (Be careful not to download chapter update patches or old editions of the book.) “Key vaccine information” Monographs on individual vaccines written in a straightforward Q&A format. However, the date of production is not included and some links in the documents are out of date. “Official immunisation letters” Communication from the Department of Health. Documents are listed in date order with the most recent at the top. “Vaccine update” Monthly publication for health professionals regarding vaccine supply. Editions are listed in date order with the most recent at the top.
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Source Notes First-line resources In-house past enquiries. Patient Group Directions Example PGDs for the administration of vaccines (and other products) are available from the PGD community area in NeLM. www.nelm.nhs.uk/en/Communiti es/NeLM/PGDs/ Health Protection Agency This website includes information on the incidence of cases of infectious www.hpa.org.uk diseases and links to UK guidelines. From the home page, click on ‘Topics A-Z’ at the top of the screen and then select the vaccine or disease you are interested in. Additional resources (tailor to local use/availability) Sanofi Pasteur MSD This website provides useful information about diseases and vaccines. www.spmsd.co.uk Click on ‘healthcare professionals’ then choose ‘Product information’ or ‘Disease information’ in the list on the left side of the screen. Health professionals can also access the company’s Vaccine Information Service (VIS). Click on the link from the homepage. It provides comprehensive information about vaccines and immunisation schedules. Free registration is required. Electronic Medicines For product information about individual vaccines. NB: Dosage Compendium schedules may differ from those recommended nationally. www.medicines.org.uk/emc Medical information, vaccine Vaccine manufacturers may be able to answer questions relating to use manufacturers. of their vaccines. For information outside of the SPC ask for ‘data on file’. World Health Organization This website includes information on international aspects of vaccines (WHO) www.who.int and immunisation including the development of new vaccines and the supply of vaccines throughout the world. From the home page, click on ‘health topics’ then ‘vaccines’ or ‘immunization’. Bibliographic databases e.g. Suggested terms: IMMUNISATION, IMMUNISATION PROGRAMMES, Medline, Embase, Medicines IMMUNISATION SCHEDULE, VACCINES, name of vaccine, management resources via VACCINATION, MASS-IMMUNISATION. NeLM Local resources
Answering the enquiry NB: Always ensure you are using up-to-date resources as changes to vaccines schedules and catch-up programmes may not be included in current editions of printed resources. Reassure callers that having an extra dose of a vaccine is not usually a cause for concern. Many preparations are formulated with multiple vaccines and it is inevitable that some patients will receive doses of vaccines they do not require. The most likely adverse effect in this situation is irritation at the site of injection. Be aware of the difference between live and inactivated vaccines. When two live vaccines (e.g. yellow fever, polio) are required, they should either be given simultaneously at different sites or with a gap of at least four weeks. Consider the risk/benefit of vaccination. In cases of unknown vaccination history, it is often considered safer to give a vaccine than to assume prior vaccination.
Keywords: IMMUNISATION, name of vaccine, name of disease
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Interactions Background information Establish patient details, including age, sex etc. Consider whether the interaction is drug-drug, drug-food, drug-test or drug-disease. Which drugs are being taken by the patient already? How long have they been taken and what are the indications? Has the enquirer read about the interaction? If so, where? If the patient is already taking both drugs, have any problems been identified or investigated? Ask for details of any suspected interaction (e.g. symptoms, lack of effect, timescales of starting drugs, any action already taken). If there is an interaction, is there any reason why alternatives can’t be used? What is the patient’s liver and renal function? Is the patient taking any other medicines, including complementary, OTC and illicit medicines? If any ongoing or future monitoring is required, who would do this?
Resources Source Notes First-line resources In-house past enquiries. Relevant Medicines Q&As via www.nelm.nhs.uk BNF www.bnf.org In the paper BNF, a ‘black dot’ implies a clinically significant interaction. In the electronic BNF, type the drug names or classes in the search box, on the results page click the ‘interactions ‘ tab. Clinically significant interactions are shaded in pink. Consider significance for your patient even if the BNF doesn’t rate the significance highly. Electronic Medicines Section 4.5 of an SPC specifically relates to interactions but also check Compendium contraindications and precautions and special warnings. Interactions listed can be theoretical; manufacturer may clarify. www.medicines.org.uk/emc Stockley’s Drug Interactions via Search by putting both potentially interacting drugs in the search box. If www.medicinescomplete.com you get no hits try using a broader term – these can be found in the grey box on the right of the screen. Natural Medicines For complementary drug-drug, drug-food, and drug-disease interactions. Comprehensive Database www.naturaldatabase.com Micromedex www.thomsonhc.com Additional resources (tailor to local use/availability) Meyler’s Side Effects of Drugs, Dukes and Aronson. Bibliographic databases e.g. Suggested terms: DRUG INTERACTION, FOOD-DRUG- Medline, Embase INTERACTIONS, HERB-DRUG-INTERACTIONS Cytochrome p450 website: Indiana university website. http://medicine.iupui.edu/flockha rt/
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Source Notes First-line resources In-house past enquiries. Antiviral drugs: www.hiv- University of Liverpool website. druginteractions.org/ Local resources
Answering the enquiry If the enquiry is prospective, reference to BNF, eMC and Stockley may be all that is required. If there is likely to be little experience with the two drugs used together e.g. new drug or rarely used, review interactions with drugs from the same class and consider the pharmacology and pharmacokinetics. Consider whether an interaction is likely, on what basis and the limitations of information (e.g. if new drug/not widely used/ previous experience with combination unlikely). Can the two drugs be given together with appropriate monitoring? If so what should be monitored and who should monitor? Could a safer alternative be used? Could a different route of administration overcome the problem? Keywords: DRUG INTERACTIONS and drug names
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New products Background information Has the product been launched in the UK? If pre-launch in UK does the enquirer know whether it is available in another country? Where has the enquirer heard about this product? Ask for exact spelling, any known manufacturer, strength, dosage form and indication. If you are asked to identify a specific clinical trial, gather as much data as possible about the trial i.e. drug name, manufacturer, results, disease area, any acronym, authors’ names, date of publication etc. What is the enquirer going to use the information for? If the enquirer is considering using the new drug supply issues may be relevant. Resources Source Notes First-line resources In-house past enquiries. Pre- launch information UKMI: New Drugs Online via This contains monographs on developmental status of several hundred www.nelm.nhs.uk or www. drugs from PII onwards. Registration is required for full access. ukmi.nhs.uk Abbreviated monographs are accessible via NHS Evidence. Put drug name and ‘NDO’ into search box to limit hits just to NDO monographs.
UKMI: Prescribing Outlook via Login required. Advanced information on drugs with market launches www.nelm.nhs.uk planned in the next 12-18 months. Confidential to the NHS produced for those with budget setting, prescribing planning and medicines management responsibilities. Brief information on: generic name, trade name, company, indication, NICE status, links to in-depth independent assessments, current status, estimated UK launch, pharmacology, efficacy, safety, target population, NHS service and financial implications. Pre-launch reviews via Login required for access to some resources. These contain more in- www.nelm.nhs.uk depth information on individual drugs produced by UKMi, NPC, LNDG. Search NeLM by drug name to locate. NeLM news via News section highlights information on new drugs in press releases. www.nelm.nhs.uk There is also a section on NeLM (password protected) where reviews produced for Individual Funding Requests (IFRs) are published. AHFS Drug Information via Try these resources if product is already launched abroad especially in Medicines Complete US. www.medicinescomplete.com Micromedex www.thomsonhc.com Internet search e.g. Google. Use for reviews published in other countries if already launched elsewhere in the world. Recently launched drugs New medicines profiles via Reviews produced within 3 months of launch on UK market. Contain www.nelm.nhs.uk information on comparative costs, place in therapy and risk management issues. Search NeLM by drug name to locate. London (Cancer) New Drugs Very detailed in-depth reviews of drugs pre and post launch. Search Group publications via NeLM by drug name to locate. www.nelm.nhs.uk
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Source Notes First-line resources In-house past enquiries. Additional resources (tailor to local use/availability) Scottish Medicines Consortium Post launch appraisals used to provide advice to NHS Boards and their www.scottishmedicines.org.uk Area Drug and Therapeutics Committees across Scotland about the status of all newly licensed medicines, all new formulations of existing medicines and any major new indications for established products (licensed from January 2002). All Wales Medicines Strategy The All Wales Medicines Strategy Group (AWMSG) provides advice on Group strategic medicines management and prescribing in Wales. www.wales.nhs.uk/ awmsg ADIS R&D database Commercial database with up to date information on all aspects of drugs in development and licence extensions. Contact your regional MI centre for details. Formulary Monograph Service In-depth reviews of products launched in US. www.formularymonographs.com Midlands Therapeutics Review Post launch information to provide advice to general practitioners for and Advisory Service (MTRAC) primary care prescribing. www.keele.ac.uk/depts/mm/MT RAC/ Northern & Yorkshire Regional Post launch information to provide advice to general practitioners for MI centre www.nyrdtc.nhs.uk primary care prescribing. Also available via NeLM. EU licensing authority European public assessment reports (EPAR) are published here. These (European Medicines Authority) are the summaries of the decisions of the EMA. It contains the SPC and www.ema.europa.eu data used to support the application in the EU. However, they take some time to be published and are only available for certain products.
US licensing authority: FDA For products launched in US. www.fda.gov National Horizon Scanning Pre-launch reviews produced on drugs that are generally at PII to PIII Centre stage. This organisation is involved in advising on NICE appraisal topics. www.pcpoh.bham.ac.uk/publich ealth/horizon Pharmaceutical manufacturer. Companies can respond to individual requests for information on drugs in development. However, depending on how far away from launch it is, you are unlikely to obtain much more information than that found in the above resources. Only use if there is little information elsewhere. Bibliographic databases e.g. Suggested terms: NEW PRODUCTS, DRUGS-INVESTIGATIONAL Medline, Embase Local resources
Answering the enquiry Depends on level of information required from superficial availability information to in-depth reviews. If only pre-launch reviews are available following product launch, use with caution as the information they contain is likely to have been superseded, especially information relating to financial planning. Keywords: NEW PRODUCT, drug name.
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Paediatrics Background information These points are in addition to those required for enquiries related to other categories e.g. ADR, compatibility, etc. Establish patient details, including age and sex. What is the weight (Kg) of the child? Confirm any discrepancy between age and weight. If weight is not known, try to ascertain whether the child is considered under or overweight for their age. For some drugs (e.g. cytotoxic agents) a more accurate dose is obtained by calculation of body surface area therefore you will need height as well as weight measurements. If the patient is a young infant (less than 3 months old) were they premature? If so, what is their gestational age? What is the intended route of administration? If the route is oral, is the child able to swallow tablets? Are there any problems that may affect drug or formulation choice e.g. renal failure, cystic fibrosis, fluid requirements?
Resources Source Notes First-line resources In-house past enquiries. Relevant Medicines Q&As via www.nelm.nhs.uk BNF for Children BNFC.org Paediatric Formulary. Not updated recently. Guy’s and St. Thomas’ & Lewisham Hospitals. Neonatal Formulary: A companion website to the book at www.neonatalformulary.com Northern Neonatal Network. provides free updates and additional information for readers (the text of the book itself is not available online). Additional resources (tailor to local use/availability) Medicines for Children 2003. Superseded by BNF for Children and no longer in print. However it RCPCH. contains useful information not readily available elsewhere. Nearest paediatric hospital The UKMi Specialist Paediatric MI Service at the Royal Liverpool pharmacy department. Children’s NHS Trust (Alder Hey) (DIAL - Drug Information Advice Line www.dial.org.uk) is currently unavailable. Contact your nearest paediatric specialist centre and take advice from their clinical pharmacists. Neonatal and Paediatric Contains links to useful documents, relevant guidelines and advice. Pharmacists Group www.nppg.org.uk Child Health Specialist Useful links to lots of child health resources. Click on the menu button Collection www.evidence.nhs.uk ‘Specialist Collections’ then ‘Search Specialist Collections’. Click on ‘Child health’. Martindale via Can sometimes be helpful. www.medicinescomplete.com Micromedex Monographs have a ‘Pediatric dosage’ section. www.thomsonhc.com
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Source Notes First-line resources In-house past enquiries. Nelson Textbook of Pediatrics. Comprehensive US general paediatric reference text, providing a good Berhman, Kleigman and Jenson. source of background information on disease states, clinical manifestations, diagnosis and treatment, in addition to information on complications and prognosis. Evidence-based Pediatrics and Covers all major childhood conditions. Includes advice on management Child Health. Moyer, Williams and how best to practice evidence based medicine with reviews of all the and Elliot. available evidence in a specific area. Forfar and Arneil’s Textbook of Evidence based reference book providing a good source of background Pediatrics. McIntosh, Helms, information on disease states. Smyth and Logan. Bibliographic databases e.g. Suggested terms: CHILD (explode term), restrict search to documents Medline, Embase, Pharmline relating to specific age ranges, INFANT-NEWBORN, INFANT- (via the medicines management PREMATURE, NEONATAL DISEASES. section of NeLM) Local resources
Answering the enquiry Consider whether recommendations are within the drug’s licensed indications or whether you are advising off-label use. Prescribing unlicensed medicines, or medicines outside the terms of their licence (off-label), alters the prescriber’s professional responsibility and liability. The prescriber and pharmacist should have sufficient information to support using the medicine. Be aware that the manufacturer’s patient information leaflet may not be relevant to the child and the parents should be warned of this and appropriately reassured.
When calculating a dose on a mg/kg basis never exceed the maximum recommended dose (usually the adult dose). If the child is obese consider calculating using ideal body weight.
When assessing the appropriate dose (making reference to available paediatric dosage formularies) take account of the available formulations and their suitability.
If doses require calculation based on surface area, use recognised reference tables (see back pages of BNF for Children) or a recognised formula to calculate the surface area.
With smaller doses used in paediatrics it is much easier to make ten fold errors in calculations. Be especially vigilant with decimal points or avoid using them (and quote appropriate units in full), e.g. 100 micrograms NOT 0.1mg. Do not use trailing zeros, e.g. 5mg NOT 5.0mg.
If you are unsure of your calculations, ask someone to check them. It is good practice to do this where calculations are complicated.
Always quote the dose to be administered rather than the volume of liquid to avoid potential for errors, as multiple strengths of medicines (and manufactured specials) are common in paediatric practice.
Consider timing of administration to avoid giving during school time if possible. Consider the child’s sleep pattern and hours they will be awake to avoid interrupting sleep to administer medicines. Opt for once or twice daily dosing where appropriate.
Consider formulation and appropriateness for the child’s age. As a general rule, a liquid formulation is preferable for children aged less than 5 years. Choose sugar-free formulations where available. If a sugar containing preparation has to be used, provide advice on teeth cleaning after administration to reduce the risk of dental caries.
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The availability of a formulation in an apparently suitable form does not ensure its suitability for use in paediatric patients. Consider excipients, e.g. alcohol, sorbitol. For premature or low birth weight infants with very low total fluid requirements, consider that concentrated preparations may be more appropriate than dilute preparations.
Consider how the dose will be administered: o Will an oral syringe be necessary or would it be preferable to provide a formulation where the dose is contained in 5mL? Round the dose up or down if it makes administration easier (and safer) if the medicines has a wide therapeutic range. o If the parents are considering mixing the medicine with a drink to mask the taste check the potential for drug-drink interaction and advise that they should mix with a small volume of drink. The whole drink must be consumed to ensure the intended dose is administered. o Avoid mixing or administering the dose in a baby’s feeding bottle. o If no suitable liquid formulation is available, consider the possibility of crushing tablets or opening capsules and mixing with a small amount of soft food, again ensuring the whole dose is consumed. Always consider potential for drug-food or drug-drink interaction. Remember this renders the product unlicensed. o Avoid intramuscular injections where possible. The exception to this may be for one off doses where there is no other suitable formulation, e.g. vaccines.
If you are considering recommending an extemporaneous preparation, consider how supply will be continued in the longer term. The local community pharmacist may require details of special-order manufacturers to obtain the product. Remember that special-order products can be very expensive.
Keywords: CHILD, INFANT, INFANT-NEWBORN INFANT-PREMATURE NEONATAL DISEASES, PAEDIATRICS and relevant drug names.
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Palliative care Background information Is the palliative care team or MacMillan nurse involved in the patient’s care? There is a MacMillan nurse attached to every GP practice who will know their palliative care patients. For enquiries about managing a specific patient (other than straightforward medicines information queries), advise the enquirer to contact this nurse. If the enquirer asks about compatibility of drugs in a syringe driver, check the drugs, doses, diluents and volume. If the enquirer asks about symptom control, establish indication and what drug or non-drug options they have tried already. If the patient is unable to tolerate oral administration, can other routes be used? Check concomitant medication and concurrent disease including renal and liver function. If the enquiry is related to conversion between different opioids, what is the total daily (24 hour) dose, including PRN doses, currently being taken? Is the patient’s pain well controlled? N.B. If the enquiry concerns the subcutaneous administration of medicines via a syringe driver please also refer to the ‘Compatibility of subcutaneous drugs’ monograph.
Resources Source Notes First-line resources In-house past enquiries. Relevant Medicines Q&As via www.nelm.nhs.uk BNF www.bnf.org Section on prescribing in palliative care includes information about drug administration via syringe drivers. Palliative Care Formulary Textbook available free online. Once registered, click on the menu (PCF3). Twycross et al. button ‘Formulary’, then the chapter you require. Paper version also www.palliativedrugs.com available. Symptom Relief in Palliative Freely available via NHS Evidence. Click on the menu button ‘NHS Care. Dean, Harris, Regnard Athens Resources’ then ‘E-books’. Log in with your Athens password. and Hockley. Type ‘symptom relief’ in the search box. Click on ‘Read Book’. Paper version also available. Additional resources (tailor to local use/availability) Palliative Care Matters website Website for healthcare professionals working in palliative care. www.pallcare.info Palliative Medicine Handbook. Textbook available free online. Includes an interactive opioid dose Ian Back. converter. www.book.pallcare.info Oxford Handbook of Palliative Freely available via NHS Evidence. Click on the menu button ‘NHS Care. Watson M et al. Athens Resources’ then ‘E-books’. Log in with your Athens password. Type ‘oxford palliative’ in the search box. Click on ‘Read Book’. Paper version also available. Oxford Textbook of Palliative Freely available via NHS Evidence. Click on the menu button ‘NHS Medicine. Hanks G et al. Athens Resources’ then ‘E-books’. Log in with your Athens password. Type ‘oxford palliative’ in the search box. Click on ‘Read Book’. Paper version also available.
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Source Notes First-line resources In-house past enquiries. Supportive and Palliative Care in Freely available via NHS Evidence. Click on the menu button ‘NHS Cancer: An Introduction. Athens Resources’ then ‘E-books’. Log in with your Athens password. Regnard and Kindlen. Type ‘supportive’ in the search box. Click on ‘Read Book’. Paper version also available. A guide to symptom relief in Includes a chapter ‘Getting started’ on how to discuss problems with advanced disease. Regnard and patients. Tempest. Symptom management in Not updated since 2001. advanced cancer. Twycross and Wilcock. Macmillan Cancer Support Macmillan has merged with Cancerbackup. The website offers an www.macmillan.org.uk information service for patients about cancer and its treatments (‘Cancer information’ section). Within this section is an area for health and social care professionals containing free information resources. Also links to sites listing current UK and European cancer research trials. Marie Curie Cancer Care Website provides information for people with cancer and other www.mariecurie.org.uk conditions, including information sheets on managing symptoms (in the ‘Patients, carers and families’ section). The healthcare professional section has a professional development section with links to training resources. There is a link to the website of the Liverpool Palliative Care Institute, which produced the Liverpool Care Pathway, a multiprofessional document which provides an evidence-based framework for end-of-life care. Supportive and Palliative Care The Supportive and Palliative Care Specialist Collection aims to provide Specialist Collection convenient and comprehensive access to the best available evidence in www.evidence.nhs.uk all aspects of supportive and palliative care. Click on the menu button ‘Specialist Collections’ then ‘Search Specialist Collections’. Click on ‘Supportive and palliative care’. Bibliographic databases e.g. Suggested terms: PALLIATIVE TREATMENT, PALLIATIVE-CARE. Medline, Embase, Pharmline (via the medicines management section of NeLM) Local resources
Answering the enquiry Many uses of medicines within the field of palliative care are unlicensed, but are based on current clinical practice. Equivalent doses between opioids are approximate so patients must always be monitored carefully and regularly if transferred to another opioid. If you are unable to find compatibility data, think about alternative drugs, routes or separate syringe drivers. A patient’s condition can change rapidly so it is imperative that their response to drug therapy is monitored and assessed frequently. Keywords: PALLIATIVE TREATMENT, drug names.
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Pharmaceutical
Background information For enquiries about pharmaceutical excipients: What is the reason for asking about excipients? Does the patient have a known problem, or is one suspected? What is the nature of any known or suspected reactions to excipients? For patients experiencing intolerance to a product, how long has the patient been taking any medication that might be the source of the problem? What other medication is the patient taking? It may be possible to rule out suspected problems with excipients if the patient has no problems already taking medicines that contain these excipients. For enquiries about lactose or sodium content, an assessment of the total quantity provided by all of the patient’s medicines can indicate the likelihood of a significant problem occurring.
For enquiries about latex allergy: Obtain a full description of what happens when the patient is exposed to latex. Which products do they intend to use, including the brand name if possible, and why?
For enquiries about products of animal origin or suitability for patients with religious beliefs: Establish clearly which substances the patient objects to and the reason why. For example, the enquirer may ask for a gelatin-free product – gelatin usually comes from animals and so is unsuitable for vegetarians; gelatin in a non-edible form (e.g. tasteless capsule shell) is suitable for Jewish patients if no alternative is easily available; all gelatin in medicinal products is deemed suitable for Muslim patients. What is the drug to be prescribed and why? What other medication is the patient taking?
For enquiries about stability of refrigerated products at room temperature, if frozen or in compliance aids: For products that have been stored at temperatures outside the manufacturer’s recommended limits, what was the highest (or lowest) temperature, how long were the products exposed to this temperature, what are the brand names of the products and where are they stored now? For products to be stored in compliance aids, how long will the product be stored in this way and which type of aid is being used?
For enquiries about extemporaneous preparation:
Establish clearly what product has been prescribed including all ingredients, strengths and vehicles. What condition is it being used to treat? What else has been tried? If no information is available on the stability of the requested product, it may be possible to substitute the requested product with one that has been made previously or one that is from an approved list. Is there a licensed alternative available?
If the patient is a hospital inpatient, consider what arrangements need to be made to continue the supply of the product after the patient is discharged. Will a special-order manufacturer be able to supply the product? Can the community pharmacist easily obtain supplies?
N.B. If the enquiry concerns the advisability of crushing tablets, opening capsules, mixing medicines with food or drink, please refer to the ‘Administration of medicines’ monograph. See also the ‘Interactions’ monograph. If the enquiry concerns the advisability of mixing injectable products in syringes or fluid bags, please refer to the ‘Compatibility of Intravenous Drugs’ and ‘Compatibility of Subcutaneous Drugs’ monographs.
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Resources Source Notes First-line resources In-house past enquiries. Relevant Medicines Includes numerous documents on gluten, lactose and sodium content of Q&As via medicines. Also information on E-numbers and excipients in toothpastes. The www.nelm.nhs.uk Medicines Q&A on stability of products in compliance aids (Pinderfields Guide) is no longer available. BNF and BNF-C The presence of selected excipients is noted. See General guidance section for www.bnf.org and details. www.bnf-c.org Electronic Medicines Compendium www.medicines.org.uk/e mc Martindale via www.medicinescomplete .com UKMI Latex Database Updated annually (currently delayed) but advice is to confirm information with www.ukmicentral.nhs.uk manufacturer before use (requires UKMi log in). /secure/l1/latex_databas e/default.asp UKMI Fridge Database. Provides stability information for medicines, intended for storage in the fridge, www.ukmi.nhs.uk/secur inadvertently stored outside recommended storage temperatures (requires UKMi e/fridge/index.asp log in). Drugs of porcine origin Guidance booklet on drugs of porcine origin. Explains religious and cultural and clinical alternatives. aspects of porcine derived products. Also includes a section on issues for Jewish Medicines Partnership patients and explains requirement for all medicines that are swallowed to include 2004. kosher ingredients. www.keele.ac.uk/pharm acy/npcplus/medicinesp artnershipprogramme/m edicinespartnershipprogr ammepublications/drugs ofporcineoriginandclinica lalternatives/ Religious leaders’ Guidance from the World Health Organisation & the Islamic Organisation for approval for Medical Sciences stating ‘The gelatin formed as a result of the transformation of consumption of gelatin the bones, skin & tendons of a judicially impure animal is pure and it is judicially in medicinal products by permissible to eat it’. Muslims via www.immunize.org/conc erns/porcine.pdf Medicines and Staff at the MHRA Information Centre can search the licensing database Healthcare products (Sentinel) to identify products that do not contain specific excipients. Email Regulatory Agency [email protected] – enquiries are answered within 20 working days. PJ Online Article published in the Pharmaceutical Journal lists medicines and their stability in www.pjonline.com compliance aids (Church C and Smith J. How stable are medicines moved from original packs into compliance aids? Pharm J 2006; 276: 75-81). *Registration required to access the article on-line. Additional resources (tailor to local use/availability)
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Source Notes Manufacturers’ Medical Information departments. Handbook of Pharmaceutical Excipients via www.medicinescomplete .com Aulton’s Pharmaceutics. General reference textbook. Explains how pharmaceutical excipients are manufactured and used in medicines. Bibliographic databases Suggested terms: name of the excipient (as in the thesaurus provided e.g. MeSH e.g. Medline, Embase. or EMTREE). Food Additives and Includes information on E numbers, including a full list of E numbers, a description Ingredients Association of the main additive categories and an explanation of why additives are needed. www.faia.org.uk/ Coeliac UK Includes a section for healthcare professionals with advice on what gluten is and www.coeliac.org.uk how to achieve a gluten-free diet, links to coeliac disease management guidelines and a list of prescribable gluten-free foods. List of preferred A list of unlicensed dermatological preparations recommended for manufacture unlicensed and supply in NHS hospitals (includes drug, vehicles and strength). dermatological preparations (specials). British Association of Dermatologists. www.bad.org.uk/Portals/ _Bad/Specials/BAD %20Specials %20Booklet.pdf Special-order A list of special-order manufacturers is at the back of the BNF and BNF for manufacturers. Children. Trissel’s Stability of Compounded Formulations. Local resources
Note: NPA Information Leaflets ’Sugar Content of Medicines’ and ’Diluent Directory’ are no longer available.
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Answering the enquiry The individual product’s Summaries of Product Characteristics should always be checked as formulations may change and the quantities of excipients used may vary by manufacturer, product, formulation and strength.
It is our duty as a health professional to abide by the wishes of a patient, regardless of the reason why a person objects to products of a certain animal origin. Therefore, for example, if a Muslim patient refuses products containing gelatin, even after you have made them aware of the advice of the World Health Organisation and the Islamic Organisation for Medical Sciences, it is our responsibility to help them to find a suitable alternative product, if possible. Approximately a third of ‘Specials’ produced within the NHS are for Dermatology; clinicians are encouraged to prescribe from the list of preferred specials prepared by the British Association of Dermatologists. The aim of the list is to ensure quality, safety and availability of extemporaneously manufactured products. The MHRA recommends that an unlicensed medicine should only be used when a patient has special requirements that cannot be met by use of a licensed medicine.
Keywords: Name of the excipient (e.g. LACTOSE, GLUTEN, ALCOHOL, SODIUM CHLORIDE), or LATEX or ROOM TEMPERATURE/FREEZING or COMPLIANCE AIDS and relevant drug names.
Pharmacokinetics Background information What is the drug, dose, frequency, indication, route and duration of therapy? What is the patient’s age, gender and weight? What is their renal and hepatic function? (for background information required and relevant calculations please see the enquiry answering guidelines ‘Drug use in hepatic impairment’ and ‘Renal impairment’). Does the patient have any other disease states or conditions e.g. hypothyroidism, hyperthyroidism, hypoalbuminaemia? Is there concurrent medication? Have any previous drug levels been taken? If so, check the exact time they were taken in relation to drug administration and confirm the units of measurement.
Pharmacokinetic definitions and calculations Bioavailability (F): the fraction of the dose that reaches the systemic circulation as intact drug.
Bioavailability = Bioavailability factor (F) x dose
Volume of distribution (Vd): a hypothetical volume that relates the concentration of drug in the plasma to the total amount of drug in the body.
Vd (L) = Total amount of drug in the body (mg) Plasma drug concentration (mg/L)
Clearance (Cl): the volume of blood cleared of drug per unit time and the units are normally litres per hour or ml per minute.
Cl = F x (Dose/Dose interval)
Average steady state plasma drug concentration (Css)
Loading dose: the dose required to rapidly achieve the desired plasma drug concentration (C)
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Loading dose = V d x C F
Maintenance dose: the regular dose required to maintain the desired plasma drug concentration.
Maintenance dose = Cl x Css x dose interval F
Steady-state: the equilibrium achieved after multiple dosing when the rate of drug administration equals the rate of drug elimination. At steady-state the amount of drug in the body, and the plasma concentration, are constant.
Half-life: is the time taken for the amount of drug in the body (or the plasma concentration) to fall by half.
Half-life is used to determine both the time to reach steady-state conditions with chronic dosing and the time for elimination. As a rule of thumb it takes approximately 3 to 5 half-lives to achieve steady-state conditions or for a drug to be completely eliminated from the plasma.
Half-life is proportional to Vd and inversely proportional to clearance:
Half-life (hrs) = 0.693 x Volume of distribution (L) Clearance (L/hr) Resources Source Notes First-line resources In-house past enquiries. Relevant Medicines Q&As via www.nelm.nhs.uk BNF www.bnf.org Provides details of recognised therapeutic ranges for drugs that require monitoring e.g. digoxin, phenytoin. Electronic Medicines Section 5.2 ‘Pharmacokinetic properties’ provides pharmacokinetic Compendium information including absorption, distribution, metabolism, elimination and half-life. An indication of the recognised therapeutic range is usually www.medicines.org.uk/emc given within section 4.2 ‘Posology and administration’. Basic Clinical Easy to understand explanations of the basic principles of Pharmacokinetics. Winter pharmacokinetics in the clinical setting. Part One explains the basic ME. principles; Part Two illustrates, with worked examples, the clinical (Access also available online application of pharmacokinetics. – see details inside the front cover of the book). Bibliographic databases e.g. Terms include PHARMACOKINETICS, ABSORPTION, INTESTINAL Medline, Embase ABSORPTION, BIOLOGICAL TRANSPORT, TISSUE DISTRIBUTION, BIOTRANSFORMATION, DRUG ABSORPTION, DRUG ACCUMULATION, DRUG ACTIVATION, DRUG ADSORPTION, DRUG BIOAVAILABILITY, DRUG CLEARANCE, DRUG DIFFUSION, DRUG DISPOSITION, DRUG DISTRIBUTION, DRUG ELIMINATION, DRUG EXCRETION, DRUG HALF LIFE, DRUG PENETRATION, MAXIMUM PLASMA CONCENTRATION, PLASMACONCENTRATION-TIME CURVE, TIME TO MAXIMUM PLASMA CONCENTRATION, DRUG METABOLISM, DRUG RELEASE. Additional resources (tailor to local use/availability) Micromedex Pharmacokinetic section provides therapeutic drug levels, absorption, www.thomsonhc.com distribution, metabolism and excretion.
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Source Notes First-line resources In-house past enquiries. Goodman and Gilman’s Manual Chapter One provides a general overview of pharmacokinetics. of Pharmacology and Therapeutics. Avery's Drug Treatment. Chapter One provides an overview of the basic concepts of pharmacokinetics and Chapter Five addresses therapeutic drug monitoring and target concentration intervention. Pharmacokinetics Made Easy, An easy to understand explanation of pharmacokinetics with a practical Birkett DJ. approach. Applied Clinical A comprehensive and detailed text on pharmacokinetics including Pharmacokinetics. Bauer LA. practical guidance on dosage optimisation in patients with hepatic, renal and cardiac disease. Clinical Pharmacokinetics, A practical guide to the use of pharmacokinetic principles in clinical Dhillon S and Kostrzewski A. practice. Questions and answers bridge the gap between pharmacokinetic concepts and their practical application to patients. Clinical Pharmacy and Chapter Three provides a practical overview of pharmacokinetics and Therapeutics, Walker R and how it is applied for commonly used drugs with a narrow therapeutic Whittlesea C. range. Four case studies provide the opportunity to put theory into practice. Local resources Trust formularies and/or clinical Trusts will have local policies and procedures for measuring and chemistry labs and/or interpretation of drug levels. therapeutic drug level monitoring services. Answering the enquiry Always have calculations checked. Pharmacokinetic parameters in elderly and paediatric patients may not be the same as in adult patients and may alter drug response. For highly protein bound drugs consider checking albumin levels. If therapeutic drug level monitoring (TDM) is recommended ensure that levels are not taken before steady state is reached. Keywords: PHARMACOKINETICS, ABSORPTION, BIOLOGICAL AVAILABILITY, CLEARANCE-DRUG, VOLUME OF DISTRIBUTION, EXCRETION, EXCRETION-DRUG, HALF LIFE, METABOLISM, METABOLISM-DRUG, METABOLITES-ACTIVE, FIRST-PASS PHENOMENON.
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Poisoning or overdose Background information A quick response may be required if an overdose has been taken. Be aware that referral to the National Poisons Information Service (NPIS, telephone 0844 892 0111) may be required. Urgent medical attention may be necessary. What is the name of the medicine or substance? What is the brand name of the product and the ingredients? How much has been taken? How long ago was it taken? Does the person have any symptoms? Has any action been taken so far? If the person has life-threatening symptoms (e.g. is unconscious or having difficulty breathing) urge the caller to call an ambulance. What are the circumstances of the exposure? Was this an accidental or deliberate overdose? Was it an administration error? How old is the person who took it? Do they have any underlying health conditions? Is the person pregnant or breast feeding? Is the medicine or substance something the person takes regularly? If so, what is their regular dose? Was this a single overdose or have repeated overdoses been taken? If repeated overdoses, refer the caller (if a healthcare professional) to NPIS. Has more than one medicine or substance been taken? If so, consider referring the caller (if a healthcare professional) to NPIS. This may not always be necessary e.g a single additional dose of a medicine a patient takes regularly may not be cause for concern. Resources Source Notes First-line resources Toxbase www.toxbase.org Information from NPIS on the symptoms and management of poisoning by medicines, plants, household chemicals and other substances. Click on the poisons A-Z index for an alphabetical list of products and drugs. For a list of chemicals click on ‘Chemicals’, select ‘Household Chemicals’. This includes: cosmetics, hair products, household cleaners, miscellaneous, pharmaceuticals, standard formulation index, toiletries. Electronic Medicines Compendium SPC section 4.9 overdose may provide information on the www.medicines.org.uk/emc symptoms and management of toxicity.
Additional resources (tailor to local use/availability) Martindale Monographs provide information on pharmacokinetics including www.medicinescomplete.com elimination half-life. DrugDex Monographs provide information on pharmacokinetics including elimination half-life. Answering the enquiry In most cases, a single additional dose of a medicine a patient takes regularly is not a concern. If you are unable to answer the question using the resources available, or are concerned that the person requires specialist medical attention, refer the caller (if a healthcare professional) to the National Poisons Information Service. Document all poisoning enquiries even those you refer directly to the Poisons Information Service. Keywords: POISONING, drug name or substance name
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Pregnancy Background information Is the patient already pregnant? Is the patient already taking the medicine in question? If pregnant, how many weeks pregnant is the woman? Has the woman had any previous pregnancies? Does she have a history of miscarriage or malformations? Did she take medicines during previous pregnancies? Establish dose, frequency, indication, route of medicine taken / intended to be taken. Establish the current situation. Is the medicine still being taken or has it been stopped? Is the woman taking any other medicines? Is drug therapy necessary? Have other therapies/medicines been tried? Have any investigations been performed? If referring to NTIS for further information, ensure you have GP or Consultant contact details and a patient identifier that will distinguish the patient if follow up is required. Resources Source Notes First-line resources In-house past enquiries. Relevant Medicines Q&As via www.nelm.nhs.uk British National Formulary Information on drug safety in pregnancy is included in drug monographs. www.bnf.org (There is no longer a separate appendix.) BNF for Children www.bnfc.org Information on drug safety in pregnancy is included in drug monographs. Electronic Medicines SPC section 4.6 (pregnancy and lactation) clarifies the licensed status of Compendium medicines use during pregnancy. NB: Statements in SPCs are www.medicines.org.uk/emc sometimes more cautious than current evidence requires and it is worth checking other sources. Toxbase www.toxbase.org Monographs from the UK Teratology Information Serice (UKTIS) are available on this website. Click on ‘specialist areas’ then ‘exposures in pregnancy’. Monographs are listed alphabetically by drug name. Toward the bottom of the screen are monographs on the management of various conditions during pregnancy. The date of revision is on each monograph. If a monograph is old, contact UKTIS for further information. Drugs during Pregnancy and Chapter 1 provides a useful overview of the risks of drug use in Lactation. Schaefer. pregnancy. Chapter 2 contains information on drugs in pregnancy by therapeutic class. Each monograph has a boxed ‘recommendation’ at the end that may suggest suitable alternatives. Drugs in Pregnancy and Drug monographs are listed in alphabetical order and provide in-depth Lactation. Briggs et al. data. Additional resources (tailor to local use/availability) UK Teratology Information UKTIS (Telephone 0844 892 0909) provides information to medicines Service (UKTIS), UKMi information centres on the safety of medicines in pregnancy. Before specialist centre for drugs in contacting UKTIS ensure you have checked all available resources and pregnancy. have obtained all the background information.
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Source Notes First-line resources In-house past enquiries. Prescribing in Pregnancy. Rubin Chapter 1 of this UK reference includes a table showing the time and D. stages of embryo and foetal development. Chapter 2 discusses the management of common, minor and self-limiting conditions. Other chapters cover the management of chronic conditions and drug abuse during pregnancy. Handbook of Obstetric Medicine. Early chapters cover the management different disease areas during Nelson-Piercy C. pregnancy. Later chapters consider the differential diagnosis of medical problems in pregnancy. Maudsley Prescribing Chapter 7 contains a section on the choice of medicines for psychiatric Guidelines. Taylor D et al. conditions in pregnancy. Psychotropic Drug Directory. Chapter 3 contains a section on the choice of medicines for psychiatric Bazire S. conditions in pregnancy. Bibliographic databases e.g. Suggested terms: PREGNANCY, PREGNANCY-COMPLICATIONS, Medline, Embase, Medicines ABNORMALITIES-DRUG INDUCED, CONGENITAL MALFORMATIONS Management resources via plus individual drug name NeLM Local resources
Answering the enquiry Consider the benefits and risks of medication to both the expectant mother and developing baby. Consider the implications of unmanaged acute and chronic conditions on the expectant mother’s and developing baby’s health. Consider the period of gestation and, if possible, avoid all drugs during the first trimester. Where appropriate, use the lowest effective dose for as short a period as possible. Older drugs are often preferred to newer drugs as there is more information about their safety. Avoid polypharmacy where possible. Remember to consider maternal contraindications and precautions. Reassure the patient/enquirer if the drug has already been taken and if there is no indication from the literature that the drug poses significant harm. The ‘all-or-nothing’ effect applies to medicines taken during the pre-embryonic phase (the first 17 days after conception). During this time, if most of the cells are affected, the pregnancy is spontaneously miscarried but if only some of the cells are affected, these appear to be replaced resulting in a healthy embryo. Most women will not yet have missed their first period and so may be unaware of the pregnancy at this stage. Consider the half life of the drug and the date of the last menstrual period. Detailed scans during pregnancy may be appropriate if a medicine has been taken. Remember there is a background risk of major congenital malformations of 2-3% in the population. Keywords: PREGNANCY plus drug name and disease name (if appropriate)
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Drug use in psychiatry Background information If patient specific, establish patient details, including age, sex etc. Establish current and previous medical history, drug history (including OTC and illicit drugs). Is the enquiry about a drug interaction or an adverse drug reaction? If so see guidelines specific to these types of enquiry.
Resources Source Notes First-line resources In-house past enquiries. Relevant Medicines Q&As via www.nelm.nhs.uk BNF www.bnf.org Martindale via Useful for information on uses, doses and interactions. www.medicinescomplete.com Electronic Medicines Check relevant SPCs Compendium www.medicines.org.uk/emc Psychotropic Drug Directory, Bazire S. Maudsley Prescribing Guidelines, Taylor D et al. Additional resources (tailor to local use/availability) NICE Guidance – Mental Health and behavioural conditions, http://guidance.nice.org.uk/Topic /MentalHealthBehavioural Department of Health – Mental From the home page click on ‘Healthcare’ then ‘National Service health section, www.dh.gov.uk Frameworks’ then ‘Mental health’. UK Psychiatric Pharmacists Includes; clinical guidelines, medicines management, Patient Group Group (UKPPG) Directions and miscellaneous documents from UK Trusts. www.ukppg.org.uk The Royal College of Includes useful fact sheets about mental health conditions and treatment Psychiatrists www.rcpsych.ac.uk options. NHS Evidence Specialist Library The Mental Health Specialist Library aims to meet the information needs via of health care professionals who work in the field of mental health. www.library.nhs.uk/mentalhealth Bibliographic databases e.g. Suggested terms: ANTIDEPRESSIVE AGENTS, TRICYCLIC, Medline, Embase, Pharmline SEROTONIN UPTAKE INHIBITORS, ANTIPSYCHOTIC AGENTS (via the medicines management NEUROLEPTIC AGENT, SEROTONIN REUPTAKE INHIBITOR, section of NeLM). TRICYCLIC ANTIDEPRESSIVE AGENT. PsychINFO via Database of abstracts that covers psychological practice and research www.library.nhs.uk (e.g. drug and behavioural therapy, treatment of disease, drug addiction, developmental and educational psychology).
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Source Notes First-line resources In-house past enquiries. Choice and Medication This website offers people information about medications used in the www.choiceandmedication.org.u mental health setting to help people make informed decisions about k medication. It is aimed at patients but is a multi-sector partnership project involving Norfolk and Waveney Mental Health NHS Foundation Trust, the United Kingdom Psychiatric Pharmacy Group (UKPPG), the National Institute for Mental Health in England (NIMHE), the College of Mental Health Pharmacy (CMHP). Local resources
Answering the enquiry Document thoroughly. Be aware that psychotropic medication cannot be stopped abruptly due to risk of discontinuation reactions.
Keywords: Include drug names and disease states
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Renal impairment Background information Diagnosis and previous medical history if relevant. Establish patient details, including age, sex, ethnic origin, height, weight etc. U&Es and serum creatinine, eGFR most recent if possible. Are they stable or changing? Is the renal impairment acute or chronic? Calculate the patient’s estimated creatinine clearance (based on ideal body weight if obese)*. See notes below. Current medication- include all drugs (prescription and OTC) currently taken by the patient including doses. Is the renal impairment suspected to be drug-induced? Which drug(s) are suspected?** Is the patient receiving renal replacement therapy (RRT), if so how often and what type? o Haemodialysis (HD) o HDF (Haemodiafiltration) o Peritoneal Dialysis (PD) [automated peritoneal dialysis (APD) and continuous ambulatory peritoneal dialysis (CAPD)] o Continuous arteriovenous haemofiltration (CAVHF)/continuous venovenous haemofiltration(CVVHF) o Continuous arteriovenous haemodialysis (CAVHD)/continuous venovenous haemodialysis(CVVHD) o Continuous arteriovenous haemodiafiltration (CAVHDF)/continuous venovenous haemodiafiltration (CVVHDF) If requesting advice on dosage or suitability of a drug in renal impairment, what is the indication for the drug and have alternatives been considered? What agent would normally be used if the patient did not have renal impairment?
*Measurement of renal function Accurate measurement of renal function is essential in patients with renal impairment so that drug dosages can be adjusted accordingly. The estimation of glomerular filtration rate (eGFR) provided by the Modification of Diet in Renal Disease trial (MDRD) is now the routine method of estimating renal function within the NHS. It is calculated differently to the traditional Cockcroft and Gault (C&G) estimation of creatinine clearance (CrCl). The vast majority of published data on drug dose adjustment for patients with renal impairment have been based on estimations of CrCl using C&G.MDRD has not yet been validated for drug dose calculations.
MDRD generally underestimates GFR whilst C&G overestimates it. Also, with MDRD being normalised for a surface area of 1.73m2, there is a concern that patients could be incorrectly dosed by switching to MDRD unless it is adjusted for body surface area GFR Absolute = eGFR × (individual’s body surface area/1.73). Adjustment for body surface area is particularly important for patients in whom the eGFR falls on or near the boundary between moderate and severe renal impairment, or for patients at extremes of body weight. Estimates of eGFR or creatinine clearance are only valid with stable serum creatinine (over a period of several days or more). The BNF advises that in practice, for most drugs and for most patients (over 18 years) of average build and height, eGFR (MDRD ‘formula’) can be used to determine dosage adjustments in place of creatinine clearance. For potentially toxic drugs with a small safety margin, creatinine clearance (calculated from the Cockcroft and Gault formula) should be used to adjust drug dosages in addition to plasma-drug concentration and clinical response. In patients at both extremes of weight (BMI of less than 18.5 kg/m2 or greater than 30 kg/m2) the absolute glomerular filtration rate or creatinine clearance (calculated from the Cockcroft and Gault formula) should be used to adjust drug dosages. The MDRD equation should not be used for children.
In adults eGFR will be calculated by the laboratory using the 4-variable MDRD equation. The four variables are serum creatinine concentration, age, sex, ethnic origin (for African-Caribbean people only, eGFR multiplied by 1.212). The eGFR will be reported as mL/min/1.73 m2. When eGFR exceeds 89 mL/min/1.73 m2 values will usually be reported as > 90 mL/min/1.73 m2. 3
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The Cockroft and Gault equation. N.B. If obese use ideal body weight. CrCl (male) = 1.23 x (140-age in years) x weight in kg serum creatinine (micromol/l) CrCl (female) = 1.04 x (140-age in years) x weight in kg serum creatinine (micromol/l)
** If the renal failure is suspected to be drug related please refer to the monograph on ‘Adverse drug reactions’
Information required by the specialist drugs in renal disease centre (Bristol) Before contacting the specialist centre please have the following information for patient specific enquiries: Age and weight of patient. Degree of renal impairment– CrCl or recent serum creatinine levels. Is renal function stable or deteriorating? Which, if any, renal replacement therapy is being used? Is the patient currently taking the drug in question, and if so what dose? Any other medication? Any other medical problems?
Resources Source Notes First-line resources In-house past enquiries. Relevant Medicines Q&As via www.nelm.nhs.uk BNF www.bnf.org Where care is needed when prescribing in renal impairment, this is indicated under the relevant drug in the BNF. Use this as an initial source but it is inadequate as a sole reference source. Electronic Medicines SPCs should always be checked as they may give advice on the need to Compendium reduce doses and a suitable regimen in renal impairment. This is www.medicines.org.uk/emc particularly important for new drugs, as the SPC is usually very detailed and there are often no additional published data. The Renal Drug Handbook. Drug monographs suggest doses in renal impairment and in patients Ashley C et al. undergoing renal replacement therapies (UK book). Introduction to Renal This discusses diseases affecting the kidney and their management Therapeutics. Ashley C & rather than providing dosing guidance. Useful for background Morlidge C. information and general principles of dose adjustment in renal impairment and renal replacement therapies Drug Prescribing in Renal Information on doses of drugs separated into different clinical areas (US Failure: Dosing Guidelines for book). Note latest edition (5th ) divided into ‘adult’ and ‘paediatric’ tables Adults. Aronoff GR et al. eGFR calculator. The Renal Online calculator for eGFR. Has link to UK eCKD guide plus other useful Association background information www.renal.org/eGFR/ http://www.renal.org/home.aspx Renal association home page
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Source Notes First-line resources In-house past enquiries. Martindale via www.medicinescomplete.com AHFS Drug Information via www.medicinescomplete.com Meyler’s Side Effects of Drugs. For information on drug-induced renal impairment. Dukes and Aronson (or other side effects books). Additional resources (tailor to local use/availability) Therapeutic Drugs, Dollery. Monographs have information about drug use in high-risk groups, e.g. those with renal dysfunction. Useful for basic pharmacokinetic data for older drugs Micromedex Monographs have a ‘dosage in renal failure’ section. www.thomsonhc.com Bibliographic databases e.g. Suggested terms: KIDNEY FAILURE, KIDNEY FAILURE-ACUTE and Medline, Embase. KIDNEY FAILURE-CHRONIC Pharmaceutical manufacturers. Manufacturers may have information about any necessary reduction of doses in renal impairment. http://renalpharmacyconsultants. Contains general information about what factors determine whether a com/sitebuildercontent/sitebuilde drug is removed during haemodialysis and peritoneal dialysis, plus rfiles/Download2010DialysisofDr information on individual drugs. ugsGuide.pdf Dialysis of Drugs 2010 CKD Insights, Renal Pharmacy Consultants, LLC. http://www.dh.gov.uk/en/Publicat Department of Health guidance on eGFR ionsandstatistics/Publications/Pu blicationsPolicyAndGuidance/D H_4133024 Specialist Centre for Drugs in Can assist with specialist advice on drug dose adjustment in renal failure Renal Disease. South & West and renal replacement therapies. Phone them only after checking (Bristol) Medicines Information standard texts/resources :(including BNF, SPC, Renal Drug Handbook Service. Tel: 0117 342 2867. and NeLM for Q&As).Make sure you have all the relevant background information if the enquiry is patient specific. Advice on adverse effects of drugs on the kidney or drugs in renal transplantation is not provided Local resources
Answering the enquiry Patients not on renal replacement therapies (RRT): There are two approaches to altering drug maintenance doses in patients with renal impairment: o Give the standard dose at extended intervals o Give a reduced dose at standard intervals Loading doses or single doses will be the same as for those with normal renal function. When choosing a drug for patients with renal impairment: o Only use drugs where there is a definite indication for prescribing o Choose a drug that has minimal or no nephrotoxicity o Use recommended dosage regimens for renal impairment o Use plasma concentration measurements to adjust dose if possible and relevant
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o Monitor for evidence of clinical efficacy and toxicity
Patients on renal replacement therapies (RRT) – for more in-depth guidance see Medicines Q&A What factors need to be considered when dosing patients on renal replacement therapies? : There are a number of factors that need to be considered when dosing patients on RRT. Consider the drug, the patient and the type of RRT. Dose adjustment for RRT is only necessary for drugs that require dose adjustment in the presence of renal failure. No RRT is as effective as the normal kidney – so doses used will never be larger than those recommended in normal renal function. Alteration of drug dosage is only necessary if renal clearance exceeds 25% of total body clearance. Drugs which are cleared by the kidneys are usually dialysed, and vice versa, although there are some anomalies. Advice on drug dosage in continuous RRT (CRRT) from the literature should be applied cautiously to individual patients. These studies varied in design and calculated drug clearance by various methods. In patients on HD, dose after the dialysis session otherwise a proportion of the drug may be removed during the HD session and its duration of action reduced. For CRRT and CAPD, since these are continuous processes, there is no need to schedule doses around RRT sessions. For toxic drugs, and for drugs with a narrow therapeutic index, drug monitoring with measurement of plasma concentrations, where available, and monitoring of the patient for therapeutic response and adverse effects, is essential. Information from specialist sources may provide dosing information outside the product licence. The omission of a drug from reference sources does not imply that the drug is safe for use in patients with impaired renal function. You should consider other therapeutic options that don’t require adjustment in renal failure e.g. drugs that are primarily metabolised by the liver. Keywords: KIDNEY, KIDNEY FUNCTION-IMPAIRED, KIDNEY FAILURE, drug name
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Medicines in sport Background information Is this a prospective or retrospective enquiry i.e. is the drug already being taken? What is the classification of the product involved e.g. prescribed medication, supplement? Does the enquiry relate to a specific sport or competition? Resources Source Notes First-line resources In-house past enquiries. Relevant Medicines Q&As via www.nelm.nhs.uk BNF www.bnf.org See under ‘Drugs and sport’. UK Anti-Doping UK Anti-Doping is the national body responsible for the implementation www.ukad.org.uk and management of the UK’s anti-doping policy and is responsible for ensuring sports bodies in the UK comply with the World Anti-Doping Code. Click on Resources then Education to access the current prohibited list, the B2 agonist Therapeutic Use Exemption (TUE) form, TUE form and UK Anti-Doping advice card. A position statement on supplements and links to further information are available. Click on ‘What we do’ then choose ‘science and medicine’. The World Anti-Doping Agency WADA is an international independent agency. It monitors the World (WADA) Anti-doping Code. The website contains a list of banned substances and information on therapeutic use exemptions (TUE) – see the ‘Quick Links’ www.wada-ama.org/en section Drugs of abuse. Wills, S. Contains a chapter on performance enhancing drugs. Pharmaceutical Press. Martindale Drug monographs note if drugs are restricted in sports, but should not be relied on as a single source. This information is usually at the beginning of a monograph, after the medicine’s chemical structure.. Additional resources (tailor to local use/availability) Drugs in sport. Mottram, DR. NB: published in 1998 so do not use as a single source Routledge UK Sport www.uksport.gov.uk Includes rules, guidelines and information. Click on ‘Explore UK Sport’ in the bottom right corner to bring up an A-Z list of site contents Relevant sport governing body Use Google to search for these. Examples are the Lawn Tennis website. Association and the Football Association. They may be websensed. Internet search engine Can be helpful in identifying claims made for products and supplements www.google.co.uk Natural Medicines Might be useful for contents of herbal products or supplements. Comprehensive Database, www.naturaldatabase.com Bibliographic databases e.g. Suggested terms: SPORT, SPORTS MEDICINE, DOPING IN SPORT. Medline, Embase. Local resources
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Answering the enquiry Athletes are personally responsible should a prohibited drug be detected in their body. Note that national legal controls vary. Keywords: SPORT plus individual drug names.
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Substance misuse Background information Illicit drug use: Is drug use suspected or confirmed? What drug or substance is involved? If slang names are used clarify what the drug name is. Does use of the drug relate to a single exposure, short-term use, or a persistent habit? How frequently is/has the patient/client using/used this drug? How long certain drugs stay in the body is influenced by how often the patient is using it. How is the subject taking the drug (e.g. injection, oral)? The form of the drug and knowing how a patient is taking a certain medication may make a difference to your answer. Is the subject taking other illicit drugs? It may be important to know about other substances (e.g. tobacco, prescribed drugs). How confident are you that the amount of drug taken and the frequency of use is correct? Users may lie about the quantities consumed and the purity of street drugs also varies widely. Why are you being asked for the information? These enquiries can raise ethical/legal issues due to the nature of the drugs involved. It is essential all background details are obtained to help assess if you can answer the enquiry and what information you can give. Has a drug test been performed or ordered? What were the results or when are they expected? Are the Community Drug and Alcohol Team (CDAT), or similar involved in the management of this patient? Ask about other medicines or medical conditions. Many enquiries concern identification, side effects, interactions or use in pregnancy. Refer to appropriate enquiry answering guideline. Drug withdrawal: Has the drug/substance been withdrawn or is withdrawal being considered? What is the reason for withdrawal? If for urgent medical reasons, withdrawal may need to be immediate, with the actual withdrawal effects assuming secondary importance. Does the patient agree with the decision to withdraw the drug? Without the patient’s co-operation, attempts at withdrawal are not likely to succeed. Has withdrawal been attempted before? How was it done? What happened? Is withdrawal the only option? Have other options been considered (e.g. maintenance therapy)?
Resources Source Notes First-line resources In-house past enquiries. Relevant Medicines Q&As via www.nelm.nhs.uk Drugs of Abuse, Wills S. A comprehensive source of information on drugs of abuse including prescription drugs, OTC preps, alcohol, caffeine, nicotine and plants. Pharmaceutical Press. Includes information on uses, side effects, interactions, use in concomitant disease states and useful websites.
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Source Notes First-line resources In-house past enquiries. Department of Health (England) http://www.nta.nhs.uk/areas/Clinical_guidance/clinical_guidelines/docs/cl and the devolved administrations inical_guidelines_2007.pdf (2007). Drug Misuse and Produced by the National Treatment Agency for Substance Misuse, on Dependence: UK Guidelines on behalf of the Department of Health. Contains practical advice on drug Clinical Management – “The withdrawal, drug testing and other health considerations. Orange Guide”. Psychotropic Drug Directory, Contains a chapter on substance misuse. Bazire S. Maudsley Prescribing Contains information on interactions with alcohol, cannabis, cocaine and guidelines, Taylor D et al. smoking. Additional resources (tailor to local use/availability) Clinical Knowledge Summaries Covers the management of opioid dependence in adults. The guideline – Opioid dependence provides information on substitution therapy with methadone and www.cks.nhs.uk/opioid_depend buprenorphine. ence Clinical Knowledge Summaries Covers the assessment of a person who is being prescribed long-term www.cks.nhs.uk/benzodiazepine benzodiazepines or z-drugs, and offers advice on managing withdrawal of _and_z_drug_withdrawal treatment. NICE guidance - Drug misuse: This guideline makes recommendations for the treatment of people who opioid detoxification CG52, July are undergoing detoxification for opioid dependence arising from the 2007 misuse of illicit drugs. http://guidance.nice.org.uk/CG52 Talk to Frank, Department of Health backed site, which is aimed at concerned parents www.talktofrank.com and young people, answering their questions about drug misuse. Provides contact details if they need to speak to someone. Drugscope, Drugscope is a UK independent organisation with expertise on drug use. www.drugscope.org.uk The website includes brief information about the law, uses and risks associated with drugs, including plants and prescription medication. Click on resources then drugsearch to bring up an A to Z list of drugs and substances. National Institute of Drugs of US website which contains evidence based fact sheets and resources Abuse, for healthcare professionals about drugs of abuse. http://www.nida.nih.gov/NIDAHo me.html Bibliographic databases e.g. Suggested terms: DRUG ABUSE, SUBSTANCE ABUSE, SUBSTANCE- Medline, Embase. ABUSE-INTRAVENOUS, SUBSTANCE-RELATED-DISORDERS, INTRAVENOUS DRUG ABUSE, MULTIPLE DRUG ABUSE. Local resources
Answering the enquiry It is important to consider the ethical/legal implications surrounding these types of enquiry. If you are in doubt as to what information you should give the enquirer discuss with MI colleagues. Remember with some of these agents there is limited information available so be aware when giving advice particularly in patients with concomitant medical problems or those on other medication. Keywords: DRUG ABUSE or SUBSTANCE ABUSE and where possible the name of the drug involved.
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Travel medicine
There are four sections to this document: Malaria prophylaxis and travel vaccinations Travel-related DVT Taking medicines abroad Other travel-related medicines enquiries
Malaria prophylaxis and travel vaccinations Background information What country/countries are to be visited? What is the departure date? How long will the visit be for? Where exactly are they travelling within the country and what type of accommodation will they be staying in? (e.g. tourist areas, safari, backpacking) Have they had malaria prophylaxis before and if so what? Did they have any problems with the prophylaxis? Have they had any vaccinations before, if so when, and did they have any problems? What medication, if any, is the traveller taking? What is the traveller's past and current medical history? Does it include: o Immunosuppression o Psoriasis o Epilepsy o Depressive or psychiatric illness o Renal or hepatic impairment o Splenectomy o Porphyria o G6PD deficiency o Sickle cell or thalassaemia Is the traveller pregnant or breast-feeding? Will any children be travelling, and if so what age and weight will they be at the time of travel?
Resources Source Notes First-line resources In-house past enquiries. Relevant Medicines Q&As via www.nelm.nhs.uk Travax database, This is a Scottish NHS website for healthcare professionals. Click on www.travax.nhs.uk ‘malaria’ or select the destination you require. NPA information sheet on Available via www.nelm.nhs.uk. Log in then click on ‘Community Areas’ malaria prophylaxis. then ‘NPA resources’.
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Source Notes First-line resources In-house past enquiries. NPA information sheet on travel Available via www.nelm.nhs.uk. Log in then click on ‘Community Areas’ vaccinations. then ‘NPA resources’. Additional resources (tailor to local use/availability) Fit for Travel, This is the Travax sister-site and can be accessed by members of the www.fitfortravel.nhs.uk public and healthcare professionals. Click on ‘A to Z site index’ to bring up a list of countries and topics. Health Protection Agency, Guidelines for malaria prevention in travellers from the United Kingdom. www.hpa.org.uk Select M in the Topics A-Z at the top of the screen, then select Malaria. Click on ‘guidelines’ for the current UK guidelines. They include a chapter on ‘special categories’ that includes information on multi-trip travel, cruises, emmigration and information on variety of patient groups. There is also a frequently asked questions chapter on malaria prevention a useful ‘Frequently asked questions’ chapter on malaria prevention. eMIMS www.mims.co.uk Includes ‘travel tables’ of malaria prophylaxis and travel vaccination requirements by country. Click ‘travel’ at the top of the page. National Travel Health Network This website has information about yellow fever vaccination centres and and Centre (NaTHNaC) website, other travel information. You do not need to log in. If you cannot find www.nathnac.org what you want on the website, healthcare professionals may telephone the NaTHNaC helpline on 0845 602 6712 (9.00 to 12.00 and 14.00 to 16.30 hours Monday to Friday). Sanofi Pasteur MSD online Registration is required to access the VIS section of the site. vaccine information service (VIS), www.spmsd.co.uk World Health Organisation, WHO guidance on International travel and health. www.who.int/ith/en/ Bibliographic databases e.g. Suggested terms: TRAVEL, ANTIMALARIALS, MALARIA, vaccine Medline, Embase. name, EMPORIATRICS. Local resources
Answering the enquiry When formulating an answer consider if there is more than one option available. The Health Protection Agency and MHRA has issued a warning against reliance on herbal or homeopathic medicines for the prevention of malaria. Try to give as much advice as possible. No prophylaxis regimen is 100% effective, so include general advice regarding protection against mosquito bites – use of mosquito nets, insecticides, insect repellents, wearing long-sleeved clothing after sunset etc. Preferred malaria prophylaxis regimens should always be recommended unless there are medical reasons why this is not possible. Alternative regimens may not give optimal prophylaxis. If pregnant, travel to malarious areas should be avoided wherever possible. If travel is unavoidable, effective malaria prophylaxis should be used, as the risk of malaria to both the mother and foetus is greater than the risk from antimalarial drugs at recommended doses. Vaccines may be administered where the risk of exposure outweighs the risk of vaccination. Breast-feeding infants will still require malaria prophylaxis, as the amounts of antimalarial drugs excreted in breast milk are too variable to give reliable protection to the infant. Most vaccines can be administered to breast-feeding women; however immunity is not passed to the infant via breast milk.
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When advising on children’s dosages, calculate the dose by weight rather than by age wherever possible. Keywords: MALARIA, PROPHYLAXIS, VACCINE and VACCINATIONS, TRAVEL, name of country, name of drugs recommended
Travel-related DVT Background information What type of travel is the patient undertaking and how long will it take? What is the traveller’s past and current medical history? Does it include: o History of DVT or PE o History of stroke o Thrombophilia o Family history of clotting conditions o Cancer or treatment for cancer Has the traveller undergone major surgery or had a hip or knee replacement within 3 months before travel? Is the traveller pregnant? What medication, if any, is the traveller taking? Does it include warfarin or aspirin, HRT or hormonal contraception? Resources Source Notes First-line resources In-house past enquiries. Relevant Medicines Q&As via www.nelm.nhs.uk Travax, www.travax.nhs.uk Log in, click on ‘advice sheets for travellers’ then ‘DVT and air flights’. British Committee for Standards www.bcshguidelines.com in Haematology guidelines on Click on ‘current guidelines’ then ‘haemostasis and thrombosis’. travel-related venous thrombosis. Additional resources (tailor to local use/availability) National Travel Health Network Click on ‘health information’ then ‘travel related DVT’ for a health and Centre (NaTHNaC) website, information monograph www.nathnac.org Fit for Travel, Click on ‘A to Z site index’ then ‘Air travel’. www.fitfortravel.nhs.uk
Bibliographic databases e.g. Suggested terms: DEEP VEIN THROMBOSIS, FLYING, THROMBOSIS, Medline, Embase.). THROMBOSIS-PREVENTION. Local resources
Answering the enquiry Patients at high risk of DVT (as per the guidelines above) should discuss their need for prophylaxis with their GP or haematologist. Flight socks are not prescribable on the NHS but may be purchased from pharmacies.
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Keywords: DEEP VEIN THROMBOSIS, FLYING, TRAVEL.
Taking medicines abroad Background information What medication is being taken abroad? Does it include controlled drugs? Are the medicines prescription only or over-the-counter? What countries are being visited? How long will the patient be out of the UK for (for questions about prescription length or continued supply)?
Resources Source Notes First-line resources In-house past enquiries. Relevant Medicines Q&As via www.nelm.nhs.uk National Travel Health Network Click on ‘health information’ then ‘medicines – transportation by and Centre (NaTHNaC) website, travellers’ for a health information monograph. www.nathnac.org HM Revenue and Customs Guidance “Taking medicines with you when you go abroad” is available http://customs.hmrc.gov.uk/channelsPortalWebApp/channelsPortalWeb App.portal? _nfpb=true&_pageLabel=pageTravel_InfoGuides&propertyType=docum ent&id=HMCE_CL_001589 Home Office Drugs Licensing Details the requirements for traveling abroad with controlled drugs and and Compliance Unit. the relevant paper work and licenses required: www.homeoffice.gov.uk/drugs/licensing/personal Additional resources (tailor to local use/availability) Embassy, Consulate or High Check the specific entry requirements for the country being visited by Commission for the country contacting the relevant Embassy, Consulate or High Commission. being visited. Where possible, obtain a letter from them before you travel. Use www.google.co.uk or the Home Office website above to find contact details. Travel Doctor, This website is maintained by a pharmacist and doctor in Wales. It www.traveldoctor.co.uk provides information about fmedicines that may be required for travel to exotic locations first-aid kits etc. It is not clear when the site was last updated. UK legislation: NHS patients www.legislation.gov.uk/uksi/1992/635/regulation/19/made (See may be removed from GP list if paragraphs 19(4) and 19(5)). abroad for over 3 months. Local resources
Answering the enquiry The legal status of medicines in other countries might differ from the UK.
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For patients travelling with controlled drugs, check entry requirements with the relevant Embassy, Consulate or High Commission. Where possible, the traveller should obtain a letter from them before travelling. GPs are not responsible for prescribing medicines for conditions which may arise during travelling, e.g. antibiotics, oral rehydration Travellers who leave the UK for more than three months can be removed from GP lists. Three months is the generally accepted maximum length for a prescription for patients travelling abroad. Keywords: TRAVEL, FIRST AID, CONTROLLED DRUGS, LEGISLATION
Other travel- related medicines enquiries Resources Source Notes First-line resources In-house past enquiries. Relevant Medicines Q&As via www.nelm.nhs.uk Travax, www.travax.nhs.uk This is a Scottish NHS website for healthcare professionals. Click on ‘advice sheets for travellers’ or select your destination. Fit for Travel, This is the Travax sister-site and can be accessed by members of the www.fitfortravel.nhs.uk public and healthcare professionals. Click on ‘A to Z site index’ to bring up a list of countries and topics. National Travel Health Network This website has information about yellow fever vaccination centers and and Centre (NaTHNaC) website, other travel information. You do not need to log in. If you cannot find www.nathnac.org what you want on the website, healthcare professionals may telephone the NaTHNaC helpline on 0845 602 6712 (9.00 to 12.00 and 14.00 to 16.30 hours Monday to Friday). Additional resources (tailor to local use/availability) Health Information for Overseas This includes sections on risk assessment and risk management and Travel (2010) – The ‘Yellow guidance for travellers with special health needs. This publication is Book’. designed to complement information found on the NaTHNaC website. www.nathnac.org/yellow_book/Y Bmainpage.htm World Health Organisation, WHO guidance on International travel and health. www.who.int/ith/en NHS Choices www.nhs.uk Includes information for travellers, those emigrating and those traveling abroad and about healthcare and also about the European Health Insurance Card (EHIC) which has replaced form E111. Click on ‘Health A to Z’ then ‘travel health’. Health Protection Agency, Provides information on travel-related infections. Click on T in the ‘A to www.hpa.org.uk Z index’ at the top of the screen then select ‘Travel Health’. Local resources
Answering the enquiry See above for information about answering questions about malaria prophylaxis, travel vaccinations, travel-related DVT or travelling abroad with medicines. Keywords: TRAVEL, name of country
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Wound care Background information Wound healing is complex and affected by patient related and wound related factors. Holistic assessment should take account of medical history as well as factors that may delay healing that include mobility, nutrition and personal circumstances. Most organisations will have a tissue viability nurse who will be better placed to advise on choice of dressings in individual circumstances. For many specialist wounds e.g. burns it is unlikely you will be asked to advise on anything other than product availability. However, in the absence of specialist healthcare professionals, the following will give you some pointers where to start. In order to advise on choice of wound management product it is better if you see the patient and their wound and consider the following: What type of wound is it e.g. surgical, pressure sore, burns, extravasation? What colour is the wound? How long has the patient had the wound? This may give an impression of complexity of the wound. What stage is the wound at i.e. does it need debridement or is it at the granulating stage? What products have been tried already and what problems have there been? Concomitant medication (may be delaying wound healing)? Are there special factors that need to be addressed e.g. high amount of exudate, malodorous? Could it be infected, if so, have swabs been taken? Any known allergies especially to wound management products?
Resources Source Notes First-line resources In-house past enquiries. Relevant Medicines Q&As via www.nelm.nhs.uk World wide wounds. The aim of this site is to be the premier online resource for peer-reviewed wound Surgical Materials management information. It contains details of published studies as well as review Testing Laboratory articles on particular subjects including maggot therapy, infected wounds, (SMTL) and the Medical dressings and bandages. Individual product datacards are also available that list Education Partnership indications, contra-indications, method of use, frequency of change, warnings, www.worldwidewounds. presentation and availability (drug tariff). com. Use the quick search facility and you will also be able to access FAQs. Dressings.org Surgical Links to same information as above but information is specific to individual Materials Testing dressings rather than containing information on the wide subject of wounds. Laboratory www.dressings.org NHS Injectable For extravasation guidance. Medicines guide www.medusa.wales.nhs. uk
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Source Notes Additional resources (tailor to local use/availability) NPCi In ‘lift’ click on ‘other therapeutics’ – there is a floor entitled ‘wound care’. From this floor you can access a range of resources as well as links to other relevant www.npci.org.uk/lift/lift.p guidance and resources including NICE, SIGN and CKS resources. These hp resources contain useful background information on this subject. MeReC bulletin via Evidence-based prescribing of advanced wound dressings for chronic wounds in www.npc.co.uk primary care Volume 21 Number 01 July 2010 This covers the following and provides useful links to other resources: What does the evidence say? What clinical guidelines are there? What clinical evidence is required for marketing approval? What are the costs of wound dressings? What does this mean for dressing choice? What about antimicrobial dressings? Do you have a local wound care formulary? (take off these hyperlinks because they all go to the top of the same page?) CKS www.cks.nhs.uk Focus search using specific wound type e.g. diabetic foot ulcer, venous ulcer etc. Wound care information A US website that is an educational tool describing aetiology, staging of wounds, network choice of products, etc. It has lots of pictures! Lists the range of products by dressing category e.g. antimicrobials, compression, absorptive, odour reducing. www.medicaledu.com www.convatec.co.uk Although this is a company website it also has some good educational sections on types of wound etc. Formulary of Wound Management Products. Morgan D. The National Provides information about prevention, recognition and management of Extravasation extravasation injuries. Extravasation injuries can be reported via this website. Information Service. www.extravasation.org.u k Online bibliographic Consider British Nursing Index (BNI) and CINAHL both of which have a nursing databases focus. Local resources Trust tissue viability nurse
Answering the enquiry If advising on choice of wound management product you will need to be familiar with the dressings you have on contract/formulary. Make sure factors that will influence wound healing have been addressed e.g. can drugs that delay wound healing be stopped/reduced, is any infection being treated?
Keywords: WOUND HEALING, WOUNDS, DRESSINGS and terms specific to wound type e.g. WOUND INFECTION, ODOURS, DIABETIC COMPLICATIONS
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Contributers: Christine Proudlove, Helen Davis, Christine Randall, Joanne McEntee, Karoline Brennan, Simone Henderson, Lindsay Banks, Jill Rutter, North West Medicines Information Centre
Comments gratefully received from: Catrin Barker, Elena Grant, Peter Golightly, Laura Kearney, Julia Kuczynska, Agatha Munyika, Janet Tweed, Paula Russell, Fiona Woods.
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