Grand Rounds 3;9

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Sources of drug information

My two most used sources for drug information are the British National Formulary and the electronic Medicines Compendium. The BNF is a joint publication of the Royal Pharmaceutical Society and the British Medical Association and is sent to every pharmacy and GP. It is the first point of call in the UK for drug information. The website is good, but registration (free) is needed for access. The eMC contains both summaries of product characteristics and patient information leaflets. SPCs are a summary of the information provided when a drug is put forward for marketing, and are the basis of the information in the BNF. The problem with eMC is that you can't link to anything which makes it useless for linking to information in blogs like this. It can also be somewhat patchy when it comes to drugs only available as generics.

There are a couple of US sites which seem fairly good from what I've seen, namely drugs.com and Rxlist. The problem with these sites is that drugs are often marketed under different names in different countries (i.e. omeprazole is Losec in the UK and Prilosec in the US), and may also have different licensed doses and indications. Of course, this assumes that a drug available in the UK is also on the market in the US.

My first choice would have to be the eMC, if only you could link to SPCs and PILs on the site.

Medicines Use Reviews

When the new contract for community pharmacy was introduced in 2005 it included medicines use reviews (MURs), designed to get pharmacists out of the dispensary and talking to patients (link opens PDF). MURs are designed to improve patient knowledge, concordance and use of medicines. Pharmacists have been slow to offer MURs, partly because of the copious amount of paperwork required with the new contract and the need for accreditation of both pharmacists and pharmacies. The reaction of some GPs has been less than complimentary. The best way to prove these GPs wrong is to produce some good quality MURs.

As part of a post-grad course I'm doing I had to conduct five MURs. So what came out of them? Well one of them was checking the patient was taking her medication correctly and knew what they were for, but then she was on nine oral medications, five of which were for high blood pressure. To go any deeper in this case would have been far outside the scope of MURs. Another of the MURs was educating a patient about asthma, including the need for regular use of preventer inhalers and allaying fears over long term use of inhlaed steroids. Next up I had an elderly gentleman who was taking diclofenac and omeprazole. Except he wasn't taking the omeprazole, so he had no protection for his stomach from the diclofenac, and he was wasting NHS money. So I explained the reason for taking omeprazole was so that he didn't end up with a nice gastric ulcer, and hopefully he'll take them from now on. I then saw a patient who was being prescribed standard release dipyridamole twice daily, when she should have been on the modified release product if she is taking it twice a day. This patient is also on low-dose aspirin, which increases the risk of gastric ulcers, but is not on anything to protect her stomach, so I suggested her GP start omeprazole 20mg daily. The final patient I saw had some fairly easy things to change to make her life easier, such as changing from simvastatin 20mg 2 at night to simvastatin 40mg 1 at night. This patient was also on co-amilofruse, a combination of furosemide and amiloride. Very few people actually need the amiloride and this patient could not remember having any blood test, so I suggested the GP review the need for the compound product. This patient was also taking Nytol (diphenhydramine) every night without her GP's knowledge so this was passed on to her GP.

From five MURs I found three people that either weren't on a gastroprotective agent or weren't taking it properly, three cases where formulations or strengths should be changed and one case where someone was taking regular over the counter medication that her doctor should have known about. I also had the oppourtunity to educate these patients about the use of their medicines and their disease states which is always beneficial. Hopefully this shows that MURs are beneficial for patients and are not just more paperwork for GPs to read. If anyone in the UK wants to make their pharmacist happy, and probably surprised, go and ask for a MUR.

Ask About Medicines Week

This week is Ask About Medicines Week,
with an overall theme of asking about medicines as we get older. There are many commonly used medicines that can be dangerous in the elderly. In particular, aspirin and anti-inflamatory painkillers, such as ibuprofen, must be used with great caution given that they can cause stomach ulcers and can precipitate renal failure and heart failure.

It should not however take a PR campaign to encourage people to ask about their medicines. If patients have any questions about their medication they should feel free to ask their pharmacist, and pharmacists should be checking whether patients have any questions.

Bad pharmacists

Bad pharmacists really irritate me. I got a prescription for my partner at 9:30 tonight, from a 100 hour pharmacy. The script was for Naproxen 250mg, one three times a day, and Co-codamol, 30/500mg, two four times a day. Now my partner has never been to this pharmacy before, so the pharmacist didn't know if these drugs had been taken before. But what happened? The prescription was dispensed and handed to me with absolutely no adivce whatsoever. This is unacceptable. It's not as if the pharmacy was busy - I was the only one anywhere near it, so it must be either laziness or incompetence. Either way it's just not good enough. Both of these drugs need counselling on, or at least checking if they have been taken before. Co-codamol can cause drowsiness and constipation, and contains paracetamol, while naproxen needs to be taken with food. Naproxen is also in the same group of drugs as ibuprofen, so it is important that they are not taken together. There was also no patient information leaflet with the naproxen - it is now a legal requirment to supply a PIL with all dispensed medicines. I think I might be phoning the manager tomorrow to complain, as this is just not on.