Dr Crippen and Quackitioners

We all know that Dr Crippen of NHS Blog Doctor doesn't like nurse practitioners, who he so kindly refers to as 'quacktitioners', but now he has taken a pot shot at pharmacist with a special interest(PHwSI). Now just in case Dr Crippen doesn't realise this, pharmacists do four years at uni, followed by a years on the job training (a pre-registration year). To become a PHwSI you would no doubt have to do a clinical diploma which takes another two years, and most pharmacists don't start these just after registration. So a minimum of six years training until a pharmacist could be a PHwSI. Lets not also forget that pharmacists get taught far more about drugs than doctors do - we don't really have to worry to much about diagnosis.

Dr Crippen comes across as a GP who has been qualified for quite a while and seems to take the view that no one can do any job better than a medically trained person. But how good are GPs at dermatology? My experience is that they are not that good - I've spoken to a GP with a special interest in dermatology who complained that GPs were prescribing oral antibitotics for acne without a topical treatment, and I've also had a patient who I found out was using Fucibet (fusidic acid, which is an antibiotic, and betamethasone which is quite a strong steroid) on her face! Dermatology is also an area that is conducive to management by people other than doctors - I'm no dermatology expert but I generally see at least one skin rash per day and normally have a decent idea of what it is and how to treat it, and those patients I send to their GP normally come back with a prescription for what I was expecting.

The question is why is Dr Crippen so defensive and so against pharmacists or nurses looking after certain conditions. What would he think if he knew that I was responsible for the care of some patients on warfarin?

At the end of the day there are lots of patients out there with chronic diseases. Doctors, pharmacists and nurses should be working together to look after these patients, after all there are more than enough of them to go round, and GPs can get money from work done by other people (I've got 80 COPD patients to check inhaler technique for, so that the GP practice can get their QOF points). Pharmacists are not generally diagnosticians, (PHwSI may be an exception) but we are eminently qualified to look after patients with established diseases.

I'm back

Sorry for the long absence, but lots of things have been going on since the summer. I've left the branch I was managing (for a number of reasons), did some relief work across the south east for a few months and am now at one branch full time because I've replaced one of my friends who has gone back to Australia to study medicine as a postgrad. The bonus is that my trip to work is about 30 seconds as I'm living in the flat above the pharmacy.


I've also been busy with my clinical diploma and all is going well. The exam was a few weeks ago and seemed to go ok, apart from a question on baby milks. I also have a new girlfriend, so am very happy and content at the moment.

I'll try and post more regularly in the future as I get back into the habit. The branch I'm at now does 20,000 items a month, so we have quite a few interesting patients to discuss.

50% increase! Are you having a laugh?

I've just found out that my retention fee for the Royal Pharmaceutical Society is increasing from £283 this year to £425 next year. Yes, we were warned about a 'significant increase' , but 50% is a bit more than a significant increase! Not only is the increase bad enough, but the Society is still way behind the times. Retention fees are payable in full at the start of January - there is no option to spread them over the year. Apparently this is because the bylaws say that retention fees have to be paid in full by a certain date. Well change the bloody bylaws then! Still, it should be about the only time minutes from council meetings are interesting and worth reading.

The Welsh Pharmacist has a more, erm, acerbic take on this.

Mark Cheesman has also set up a petition, demanding the Society reconsiders the increase in retention fees.

Interesting patients

A lot of my job has the potential to be quite monotonous. Most diabetics, hypertensives and asthmatics are managed according to national guidelines, for example. Every now and then though you get a really interesting patient. I've had a couple of these patients over the last few months.


One lady, lets call her Jennifer, has a complicated pain management regimen. Not only is Jennifer on modified release oxycodone and immediate release morphine, which is strange enough, she is also on fentanyl lozenges. I had never dispensed fentanyl lozenges before, so had to make some phone calls to find out some information about the equivalence between fentanyl lozenges and oral morphine. I have no idea why Jennifer is on three different opioid painkillers - patients are normally on a prolonged release and immediate release version of only one, as it makes adjusting the dose a lot easier.

Another lady, lets call her Emma, is being treated for toxoplasmosis. Toxoplasmosis is caused by a parasite found in undercooked meat and in cat faeces. Normally infection does not cause any problems and is dealt with by the body's immune system. However, the infection can sometimes spread to the eye and cause problems. It looks like this is what happened in Emma's case, as the prescription for her treatment was written by a consultant opthalmologist, who helpfully left his mobile phone number on the prescription. Toxoplasmosis is normally treated using a combination of pyrimethamine and sulfadiazine, neither of which are common stock in community pharmacy. Patients are also given folinic acid, to reduce the side effects of the treatment. I also had someone on the phone from the hospital pharmacy department a few days later wanting to check whether the prescription was for folic acid. I seriously hope it was a technician and not a pharmacist, but don't hospitals have copies of Martindale?

I've also had another patient, James, who has been off somewhere exotic and come back with schistosomiasis, a nice little parasitic infection caused by flukes. Now we don't get too many cases of this in the UK, and there is not actually a medicine on the UK market to treat it. The recomended treatment is with praziquantel, which has to be ordered directly from Merck, the manufacturers. James needed six tablets. Praziquantel comes in a pack of 90, costing over £300, and although I can claim payment for the whole pack I am now left with 84 of these tablets sitting on my shelf until they go out of date.

Oh, and I also have a couple of patients on Glivec, at a cost of about £1500 per month each to the NHS. Glivec is a very good and groundbreaking drug, but it is not cheap.

Product advertising

Now this is a certainly an interesting way to advertise your product.

Viagra

This cartoon is so true

£100m worth of drugs wasted each year

The BBC and the Guardian have both run a story about £100m worth of drugs being wasted each year by patients. I'm shocked. Shocked that it's only £100m per year. The real figure is going to be far higher. I have returned medicines collected every couple of months by a contractor. They normally take away seven or eight sackfuls of drugs - thousands of pounds worth. As an example, I have had two boxes of Casodex (at £240 per box), two seretide 250/25 inhalers (£75 each) and 30 diamorphine ampoules returned recently. Once something has left the pharmacy it can't be reused. There are two reasons for this. Firstly I don't know how it has been stored, and secondly I have already claimed payment for the drugs.

Some waste is unavoidable - people die, patients react badly to certain drugs. But waste can be reduced. The easiest way to reduce waste is to prescribe a months worth at a time. This also has the useful benefit of training the patients in how long it takes a prescription to be generated - they tend to forget if they only have to do it once every three months. Two or three monthly prescribing falls down because patients stockpile drugs and GPs don't always change their records. For example, someone is started on a new blood pressure tablet and is given 28 days supply (which is reasonable enough). They tolerate this new drug and their blood pressure comes down to target. However, the surgery forget to change the quantity to three months on the repeat screen. So Mrs Smith ends up with 28 days of bendroflumethiazide, 84 days of ramipril, 56 days of simvastatin, 84 days of omeprazole and 100 aspirin on her repeat prescription. And these all get ordered every month because Mrs Smith ticks all the boxes (or doesn't tick any and the surgery issue everything). This doesn't get picked up by the GP signing the prescription, and is tough for the pharmacist to pick up as well - I deal with 10,000 items per month; I don't have the time to look at every patient's records to see when they last had their drugs.

28 day prescribing also saves money - it stops people going to their GP for prescriptions for hayfever treatment for example. It is cheaper to pay the £6.85 prescription charge for two or three months worth of cetirizine than to buy it over the counter. If the prescription is only for 28, it is cheaper to buy it over the counter. I have been seeing lots of prescriptions recently for 90 cetirizine or 2 beconase nasal sprays, and it irritates me greatly.

Also mentioned in the above stories was the fact that £200m was wasted by GPs prescribing branded drugs over generic ones. The National Audit Office looked at prescribing of statins, ACE inhibitors, PPIs and clopidogrel, which account for 20% of prescribing costs between them. There are cheap and effective generic statins, ACE inhibitors and PPIs available. For example, simvastatin 40mg daily reduces cholesterol by about the same as 10mg atorvastatin daily. But simvastatin costs £3.50 per month while atorvastatin costs £18 per month. So it makes sense to use simvastatin, other than in those patients who genuinely can't tolerate it. There is also more evidence to support the use of simvastatin than atorvastatin, such as the Heart Protection Study. Clopidogrel is more interesting. It does the same job as low dose aspirin, and is often used in combination with aspirin for a year after a heart attack. Except that the combination often carries on for more than a year. Clopidogrel is also used as an alternative to aspirin for those who can't take aspirin. However, clopidogrel is actually quite similar in terms of side effects when compared with aspirin. Clopidogrel costs around £30 per month, while aspirin costs around £1 per month.

For some reason I decided to read the comments on the BBC website. That was a bad move. It is just as well I am young, otherwise I may have had a heart attack, though I definitely feel the need to bash my head against a brick wall. My neighbours may be worried about me given the amount of abuse that was coming out of my mouth, and there were times I felt like chucking my laptop out of the window. Just to address one major point that came up. There is (virtually) no difference between generic and brand name drugs. It is not unusual for them to be manufactured by the same company - Merck owns Generics UK for example. There are certain drugs which should be prescribed by brand name, and there are a few people who are sensitive to different excipients in generics, but the vast majority of patients have no problem with generics. Generics should be used whenever possible because they are far cheaper than the original brand.

Coeliac disease

Coeliac disease awareness week is coming up soon. Hence this story on the BBC website.

As it says, coeliac disease is a gut disease caused by gluten intolerance and the only treatment is a gluten free diet. So what? What is gluten? Gluten is a protein that is found in wheat, barley and rye. People with coeliac disease can't tolerate gluten - they may get diarrohea, bloating and weight loss . The presence of gluten causes an inflammatory reaction in the gut, leading to reduced absorption of nutrients and so the failure of a child to thrive may be due to coeliac disease.

But why is this a problem? Well, standard flour, as used in bread, cakes, pastries and so on is made from wheat. Therefore people with coeliac disease have to eat special gluten free products. Although some supermarkets carry a gluten free range they are more expensive than standard products, and so most coeliac patients get their foods on prescription. There is a wide range of gluten free foods available on prescription, ranging from long life breads to freshly baked breads. Pasta, biscuits, cake mixes and flours are also available on prescription.

Prescriptions for these products do occasionally cause problems. A typical prescription might read "Juvela gluten free wheat free white fibre loaf sliced". Juvela also do brown loaves, non-fibre loaves, non-sliced loaves, and so on. At least their products are long life though. Bigger problems arise when you order freshly baked products and are told they will arrive on a certain date. Of course you relay this information to the patient so they know when to collect their prescription. But then the bread does not turn up on the date you were given and you have to placate an irate patient...

Coeliac UK have a very useful website with lots of information on coeliac disease and gluten-free products and services.

The week after Easter

In the run up to Easter normally sane people go a bit crazy, just because the GP surgery is going to be closed for four consecutive days. So it's fair to say that it's quite a busy week. Things normally calm down after easter - not for me though, this week has been even busier than last week.

Today has been interesting shall we say. Firstly I had to deal with a dispensing error made by one of the pharmacists who was covering me on my week off. Zispin 30mg had been given instead of 15mg, so the patient had been taking double the dose she should have been for about a week. Unsurprisingly she had been a bit drowsy, but I managed to sort things out for her. I then had a patient in with a subconjunctival haemorrhage. These look spectacular, but in most cases aren't anything to worry about. I've had one myself - I won't go into details but it involved contact lenses and alcohol.

I've also bent the rules a few times today. Firstly I did a medicines use review with the daughters of a patient. MURs are supposed to be done with the patient, but this patient was housebound and the daughters are in and out everyday anyway so are up to speed with what's going on. Next I dispensed some out of date medicines, intentionally. I had a prescription brought in for a lady who has not got too long left. It had diamorphine (heroin) and hyoscine on it. In terminally ill patients hyoscine is used to reduce respiratory secretions ('death rattle'). So it's something that is needed fairly quickly. I didn't have any in stock, but one of the other pharmacies near by did. The only problem was it went out of date a few days ago. Damn. I really didn't want to leave this lady overnight without the hyoscine. So I phoned the manufacturers who at least confirmed there were no toxic products produced when hyoscine degrades. Of course the manufacturer came out with their standard line of 'we don't recommend you use the product after the expiry date.' Well I know this, but I don't really have much choice at the moment do I?

Reporting of benefits

I had an interesting study week on the diploma course I'm doing. One of the things we did during the week was to pick a couple of papers to pieces and look at how they discussed the results.

There are several ways the results of a study can be discussed. Obviously you have the raw numbers, but they are difficult to compare between studies. The three main ways of reporting the benefits of a treatment are relative risk reduction (RRR), absolute risk reduction (ARR) and numbers needed to treat (NNT). Relative risk reductions sound impressive, and are loved by the press and drug companies but they don't actually tell you very much. So you see headlines such as 'aspirin cuts risk of dying by 25%' or 'schoolkids use of drugs doubles'. RRR tells you, as the name suggests, the relative difference between the experiemental arm and the control arm, but, to know if this matters or not you need to know the background incidence of the event. Advertising departments of drug companies and the media often either hide away the background incidence or don't tell you it at all.

Absolute risk reductions are often small, just a few percent, and don't sound particularly impressive, but they tell you infinitely more than RRRs. Again, as the name suggests the ARR tells you the absolute difference between the control and treatment arms. However it can be difficult to translate how an ARR benefits patients. This leads on to the number needed to treat. Now the NNT does what it says on the tin. It tells you how many patients need to be treated for one to benefit and NNTs are very useful in comparing treatments.

Now for some examples. What if I told you there was an easy way to double your chances of winning the lottery? It's easy, just buy two tickets instead of one. But because your chances (or risk, or probability -they all mean the same thing) are vanishingly small to start with, doubling your chances still means they are vanishingly small: they are now just 1 in 15 million compared to the 1 in 30 million before. So the ARR in this case would be absolutely tiny. But now think about a school raffle where one ticket has a 1 in 100 chance of winning. Again there is an easy way to double your chances of winning by buying two tickets instead of one, but in this case your chances have increased significantly from 1 in 100 to 2 in 100, an absolute increase of 1%. Now the NNT is easy to calculate: it's 100/ARR. So if the ARR was 2%, you would need to treat 50 patients for one to benefit.

Sounds straightforward enough? (Or maybe not, depending how well I've explained it.) Well consider the following scenario: your hospital is considering four different cardiac rehabilitation programmes. You must choose which one you will implement. Reliable evidence shows that, during a three year period:
- Programme A reduced the rate of deaths by 20%
- Programme B produced an absolute reduction in deaths of 3%
- Programme C increased patient survival from 84% to 87%
- Programme D meant that 31 people had to enter it to prevent one death.

Which one would you choose?

This was actually the basis of a study performed by Fahey et al The figures above actually relate to the same data, just presented in different ways. Unsurprsingly they found that the programme that reported the RRR was the one chosen most often for funding.

The moral of the story is this: if you want to sell a drug report the RRR. If you want to know whether the drug is actually worth the money then look at the ARR and NNT (or speak to your prescribing advisor or community pharmacist if they are good)

Ben Goldacre probably explains this kind of thing far better than I do, and there is plenty of information on his website and in his Guardian columns.

Too funny

A couple of recent stories that made me chuckle:
Holy water not that holy
Sign up to test condoms