Documenting interventions

Community pharmacists are supposed to record the interventions they make, at least the most significant ones. This is not always easy! On Thursday I was at a busy pharmacy with just myself and a trainee dispenser in the dispensary. We were non-stop all day, so I didn't really have time to stop and document the interventions I made. There were a few really good interventions I made, which demonstrate the value of community pharmacists:

1) An elderly gentleman attempting to purchase a bottle of gaviscon for heartburn he was getting. On further questioning he had not experienced this heartburn before, and was also taking etodolac (Lodine, a non-steroidal anti-inflamatory drug). There are several sinister conditions that can present as heartburn, particularly peptic ulcers (commonly caused by NSAIDs) and gastric cancer. So this gentleman set lots of alarmbells ringing. I referred him to his GP, who told him to stop the etodolac and gave him some omeprazole.

2) Another elderly gentleman, this time complaining of a cough. He wondered if it could be caused by the salbutamol he had recently started taking. Further questioning revealed he was also taking ramipril, an angiotensin-converting enzyme inhibitors. A persistent dry cough is a classical side effect of ACE inhibitors, so this gentleman was advised to make an appointment with his GP to change his antihypertensive medication.

3) A prescription that had so many problems its tough to know where to start. The sript was for:
- bendroflumethiazide 5mg 1 daily x56
- allopurinol 100mg 1 daily x84
- irbesartan 300mg 1 daily x56
- lansoprazole 15mg 1 daily x 56
- arthrotec 75mg 1 twice daily x 60

So this gentleman's medication was all out of synch, with one month of one, two of a few others and three months of another. Now bendroflumethiazide is effective at reducing blood pressure, and at a dose of 2.5mg per day has very few side effects. Increasing the dose to 5mg has no extra BP lowering effect, but does affect body chemistry, and in particular reduces the amount of uric acid excreted from the body. Gout is caused by high levels of uric acid, which then crystallizes in the joints. Allopurinol is used to prevent attacks of gout, so giving bendroflumethiazide 5mg to a patient with gout is not the best idea in the world.

Arthrotec is a combination product of diclofenac (another NSAID, the same group of drugs as ibuprofen) and misoprostol, a prostaglandin analogue which protects the stomach from the toxic effects of the diclofenac. Lansoprazole is also a drug which is used to protect the stomach from NSAIDs, so there is no reason to prescribe lansoprazole with arthrotec. These issues were not serious enough to warrant a call to the GP, but doing a medication use review would have been a useful way of drawing these problems to the GP's attention. As I didn't have time to spend 20 minutes or more with this gentleman and the regular pharmacist doesn't do MURs, I advised him to make an appointment with his GP for a full medication review and explained the issues to him.

Ideally I would have documented these interventions, possibly on the patients medication records. However I simply did not have the time to do so, and this is one of the major challenges facing community pharmacists today. By documenting our interventions we can show the value of our role, however there often simply isn't time to do so. This is only taking into account the major interventions, and not including all the counselling we do, such as advising patients using corticosteroid inhalers (such as Becotide) to rinse their mouth after using them, or advising patients on statins to see their GP urgently if they have any unexplained muscle pain or weakness. I think the future of community pharmacy lies in robotic dispensing, freeing up pharmacist time to speak to patients and document what they do.

Clinical pharmacy

One of the problems with being a relief pharmacist is that it can be difficult to do good clinical work. Some examples from today:
1) a prescription from an extended formulary/ supplementary prescibing nurse for 56 voltarol rapid
2) a 5 day course of trimethoprim 200mg twice a day for an elderly gentleman with a urinary tract infection
3) a prescription with co-codamol 30/500 capsules, 1 four times a day and paracetamol capsules 1 four times a day.

Now none of these prescriptions is actually wrong, however there are problems with all of them. Firstly voltarol rapid (diclofenac potassium) is no more effective than standard diclofenac other than for the first few doses possibly, and is a lot more expensive. Secondly, a five day course is unlikely to cure a UTI in a male, which I told the patient. Now these are useful things to feed back to the prescriber, but not something you would phone up about during surgery and during a busy day in a pharmacy.

I did phone the doctor about the third prescription, due to the significant risk of the patient overdosing on paracetamol. It would be far more sensible, and safer, to prescribe paracetamol, 2 tablets four times a day, with codeine separately which would allow you to titrate the dose of codeine easily.When I suggested this to the GP he ignored the idea, as the patient was "happy with what he was doing." Fine, but if the same situation cropped up again I'd do the same, in the interests of patient safety.

It is far easier to feed issues back to doctors and nurses when you actually know them, and you know when is a good time to call the practice to discuss general issues. Looks like I might have to find somewhere to manage soon, so I can get more satisfaction from what I do.

Monday 23rd October

Today was my first day back at work after two weeks off. Thankfully the pharmacy I was in today was fairly quiet - we did maybe 150 items today. Nothing particularly out of the ordinary came up, though I did have a prescription for three salbutamol inhalers and one beclomethasone inhaler. Except that the patient didn't want the beclomethasone, and the patient wasn't in the pharmacy, it was his wife. So I spoke to her about the need to use steroid inhalers regularly in asthma, as they help to prevent asthma attacks. Hopefully she got the message.

Now I've just found out I've got a 75 mile drive tomorrow. Great.

My first post

Well this is my first ever post on a blog. I suppose I'll start by introducing myself a bit. I'm a community pharmacist who works in the south east of England for a medium sized chain. I have only been registered since July this year, so the last few months have been a bit of a rollercoster ride. I have recently started a postgraduate diploma in clinical community pharmacy which should keep me busy over the next couple of years.